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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 Z r.3 <br /> x (Complete in Triplicate) Date Issued:Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE 0 THE .SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THI� APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 23 <br /> JOB ADDRESS/LOCATION: { . . ,!CENSUS TRACT: <br /> OWNER'S NAME• vim% /� �Cu v� � � P PHONE:-y', -6-g <br /> ADDRESS: Qs O�cs .G_�[- € c �a,. CITY: <br /> CONTRACTOR'S NAME: ,�Na /,,;, LICENSE # ,6 CJS/ PHONE: <br /> oa.c_ v4p=_7;.4C .2007 y <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSELL TRIAL WATER W /_./ <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> , <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK j SEWER-LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> CA <br /> Q <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> a <br /> 4- <br /> N <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 OFJOA UI T U S REGU,4ATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. �. <br /> SIGNED: ;/n.c.. CONTRACTOR: dQC <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED 8Y: DATE: �.�„ .__ <br /> ADDITIONAL COMMENTS: L?---- ,' a eh&e&s e s h' u <br /> -71 2 2t7 <br /> PHASE II PHASE-III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE <br /> E H 1426 <br /> SAN JOAQUIN LOCAL_HEALTH_DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />