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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> } ilant, (Complete in Triplicate) Date Issued: <br /> • THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ibAPPLICATION IS HEREBYTO"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 /> JOB ADDRESS/LOCATION: 37// F AcaM!'o RP CENSUS TRACT: <br /> OWNER'S NAME: _ 9-f SS 7'HO Al PS A/ PHONE: 3,Cg- ,6 i ` G <br /> ADDRESS: 37 ) 1 FACAPtEO RP CITY: Ac ,a14Pa e-ALi <br /> CONTRACTOR'S NAME: Ptcv/t-fPf C 4c,,oycyLICENSE # 1(,S-71 / PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /. / TEST WELL /� _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: P 14, G L 0 wT I /.,° p u-1n/: f T A/C T A <br /> /P 7"w/2 a/A/ J <br /> (`1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> ' O <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: iter e!t.ls,tes•! T •+ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 1 <br /> APPLICATION ACCEPTED BY: <br /> �Z// f. DATE: / > <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE ,L <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br />)ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />