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w <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' `]2--1 6"0 <br /> (Complete in Triplicate) Date Issued: 3 _1 -7 v <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 IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: S <br /> ,OWNER'S NAME: YXI&S PHONE: `7-2 Z-.!j� <br /> ADDRESS: CITY: A-©Di CJ9V <br /> CONTRACTOR'S NAME: LICENSE V 2_4093 PHONE: l 9! - I.KCl^ <br /> INTENDED USE: INDIVIDUAL .-DOMESTIC WATER WELL 67 PUBLIC WATER WELL j_/ TEST WELL /_ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _ <br /> /INDUSTRIAL WATER WELL / f <br /> CAT1i0D IC PROTECTION WELL f / GEOPHYSICAL WELL / / OTHER 1_77 <br /> ' <br /> )NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD LO CESSPOOL SEEPAGE PIT �_ OTHER <br /> ^^ <br /> REPAIRS: TYPE OF REPAIRS: !1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: Tj L L AL3 <br /> ZZ <br /> i <br /> CP <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 �E RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> � V <br /> SIGNED: CONTRACTOR: }- <br /> lr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ZC lz, r DATE. <br /> ADDITIONAL COMMENTS: r <br /> PHASE Il PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE �- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTHDISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />