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FOR OF ICE,USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ] Z <br /> (Complete in Triplicate) Date Issued: j.42- 7 <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 INCOMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �j/1p 1 -5; A V ST iV CENSUS TRACT: <br /> OWNER'S NAME: COR ri S PHONE: <br /> ADDRESS: Oft IF_ CITY: <br /> CONTRACTOR'S NAME: Co LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /q PUBLIC WATER WELL /—/ TEST WELL R _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 307- SEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD_^`-CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: GR Q V11 7-01- <br /> A, <br /> 6 <br /> 6 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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: <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCE BY: A DATE: j 'Z -7 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE 3-/7- INSPECTION BY: A165=. DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />