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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. _/ 3 <br /> _ (Complete in Triplicate) Date Issued: v <br /> 9717 4TIS 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: o2 ,17642 $" g. Xd, CENSUS TRACT: <br /> OWNER'S NAME: L , N-A/, (�,s � F �/ PHONE: <br /> ADDRESS: CITY: SSC AJ. ay <br /> CONTRACTOR'S NAME: S.,7-reAj LICENSE # PHONE: 3 9�- ­'� �z <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /PUBLIC WATER WELL /—/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDULL <br /> STRIAL WATER WE / <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: 'C! e)v fav h 4 � 3�� f f 40 ge Z- A <br /> / ` g Flee � <br /> C� ~ <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> a <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: t ' f` CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y� <br /> APPLICATION ACCEPTED BY: � �� --e-�A ��`�G DATE: / <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: (� DATE �"l� �_. INSPECTION BY: 0 DATE -/g- 7Z--_ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />