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FOR Q FIGL"'iFS c APPLICATION FOR'WELL OR PUMP PERMIT PERMIT NO. /v2 — <br /> (Complete in Triplicate) Date Issued: <br /> - <br /> - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED — <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEAL�H 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 /> o� ui - B t4 ��- tq-3-31=0-'zf <br /> JOB ADDRESS/LOCATION: 2��. Q z2T c CENSUS TRACT: <br /> OWNER'S NAME: Mr. . Smith PHONE: 982-1276 <br /> ADDRESS: 270 W. Bri Gs CITY: Lathrop <br /> CONTRACTOR'S NAME: qWjp . o LICENSE # 76602 PHONE: 4b2-59 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /X/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION-WELL /_/ GEOPHYSICAL WELL / / OTHER /% <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Y <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> R <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> S <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, Q <br /> SIGNED: CONTRACTOR: Clark Well &Equip. Co. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE: Y <br /> ADDITIONAL COMMENTS: - <br /> PHASE iI PHASE III FINAL • �. <br /> INSPECTION BY: W 0-z-ymeDATE _�-^��_ Z INSPECTION BY: k) tkVc DATE Z- 1) - 72 <br /> E H 1426 SA_N_JO_AgUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />