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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Zr Z <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES_I 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 AM JOAQUIN LOCAL HEALTH'DISTRICT. <br /> JOB ADDRESSAOCATION! 19 76f_E- _111ghwM.- _1.20 --,------ CENSUS TRACT: -- - <br /> OWNER'S NAME: PHONE:8 3 -7 75--.. <br /> ADDRESS: CITY:Ri.po n <br /> CONTRACTORS NAME: -- _ LICENSE # 1_c072----- PHONE; 3 - - 0 - 00 <br /> -Jbtih Panero --- <br /> 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 / f GEOPHYSICAL WELL LL OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 1-00�SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL SEEPAGE PIT _ OTHER =_ <br /> REPAIRS: TYPE OF REPAIRS: <br /> _ (X) <br /> ABANDONHENT/DESTRUCTION- METHOD TO BE USED: �Rj11si_et.Q.jLmp--.-.._perf'orat e old 7" well <br /> cement_ from 40' to 0 <br /> It <br /> PLOT PLAN: SHOW ON REVERSE' SIDE <br /> I HEREBY CERTIFY THAT I HAVE REPARED THIS APPLICATION ANI? THAT THE WURK WILL BE DONE IN <br /> ACCORDANCE WIN THE PROVISIONS OF THE LAWS OI' THE STATE OF CALICO WU, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> I <br /> SIGNED: CONTRACTOR: <br /> J FOR DEPARTNENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY: 6P✓D- ATE: <br /> ADDITIONAL .COMMENTS: S <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: `� DATE "Z�- Z'� INSPECTION BY: Q DATE -/ - 77— <br /> INSPECTION <br /> 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WRITE-. HEALTH DISTRICT - YELLOW-PROPERTY OWNER- PINK-CONTRACTOR <br />