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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO.Y •7Z-3 5 <br /> (Complete in Triplicate) Date Issued: z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 5-aC1111 1E.1..ice• 44 le A-Ir0�d t 0,C-0—,0G <br /> JOB ADDRESS/LOCATION: �t d,41,5,4 ti F�e.,,ca j f- o s�- CENSUS TRACT: <br /> OWNER'S NAME: cr_I,, . w PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTORS NAME: I 3`]� PHONE: .4 _ (o <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /% PUBLIC WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LV�_RS.TOCW RWTU �L WATER WELL g/� INDUSTRIAL WATER WL / <br /> CATHODIC PROTECTION WELL-•/ / GEOPHYSICAL WELL /% EL <br /> OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAID°,. £TYPE .0 REPAIRS: � + <br /> n <br /> ABANDONMENT/DESTRUCTION: METHOD TO E USED* <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBYERTIFY THAT HAVE P EPARED IS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PR VISI O S 0 LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOA UIN T E $ REGULATIONS OF THE SAN JOAQUI OCAL TH D STRICT. <br /> 10 <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIT FINAL <br /> INSPECTION BY: DATE _ _ INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL_ HEALTH_DISTRICT 3/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />