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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. .27 . 7-L <br /> Complete in Triplicate) Date Issued: <br /> IS 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: 3 70•N ,8 b C /1" L2 1U 4-C A IMDU CENSUS TRACT: f A k A c <br /> OWNER'S NAME -,7/M GU/lu c i� CLL ---- PHONE: ti6 r,-_ 6o cls_ -- -_ <br /> ADDRESS: 39 L-`,"Afdj W - CITY: S,7& i/ <br /> CONTRACTOR'S NAME: �G{/t di1 LICENSE # /�Gr�-o�PHONE: _/o s-2- <br /> INTENDED <br /> '2-INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC� PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER r_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK /O r' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: -nr ` O <br /> t <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> t <br /> e I . <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE f <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 /> a , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> c � <br /> APPLICATION ACCEPTED BY: DATE: — 2' <br /> ADDITIONAL COMMENTS: <br /> i PHASE II ' PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 k' SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />