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t T <br /> F <br /> `FOR OFFICE USE: APPLICATION FOR WELL OR FUMP PERMIT PERMIT NO. <br /> 11 (Complete in Triplicate) Date Issued: _�c�-� <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 RERFORM <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: 2.3762- CENSUS TRACT: ' <br /> OWNER'S NAME: t_LZ yn I,EQFFL�ay PHONE: <br /> ADDRESS: -2-3 "762= � r 14RT"I-A CITY: C 12 t_4 <br /> CONTRACTOR'S NAME: t-/EN'/Vi/4,- LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL Z /PUBLIC WATER WELL / / TEST WELL //_7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL j / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK Sri SEWER LINES SJ PIT PRIVY AlOa4_- <br /> SEWAGE DISPOSAL FIELD !� CESSPOOL SEEPAGE PIT "tjlf.COTHER Geo /L a <br /> REPAIRS: TYPE OF REPAIRS: <br /> v <br /> W <br /> ,.J <br /> 6 <br /> N ' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: Rtit17' �/V'TO/�l T�- <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 WI H HE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF S AQUI , AND E RULES REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNEDt: CONTRACTOR: <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED _ DATE: -ADDITIONAL COMMENTS: <br /> COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY. r DATE - INSPECTION BY: �• DATE ^-1 7Z, <br /> E H`1426 k.SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br />'PISTRIBUTION: "- WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR , <br />