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a , <br /> FOR OFFICE USE: a APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ?Z- Z <br /> �Complete•in Triplicate) Date Issued: �- ZZ <br /> HIS 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 /> JOB ADDRESS/LOCATION: 9350 Alhambra Rd. CENSUS TRACT: <br /> OWNER'S NAME: Harry T. Fox PHONE: 1477 6513 <br /> ADDRESS: 1118 Porter Ave. CITY: S-tocktg <br /> CONTRACTORS NAME: J. A. Thalhamer Go# LICENSE #272303 PHONE: 1477 1858 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL H PUBLIC WATER WELL /—/ TEST WELL / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK100 ftSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 100 f=SSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: Drill and case six inch well and install pressure system <br /> W <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> a <br /> s <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: �� ec.Cti4w� CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: �12 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BYdVjA4.tL DATE V-1 7 Z <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE–HEALTH DISTRICT -YELLOW-PROPERTY OWNER– PINK–CONTRACTOR <br />