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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: µ- <br /> THIS PERMIT EXPIRES l 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: 41"J" rf w y ( "� ._ - <br /> CENSUS TRACT: <br /> OWNER'S NAME: G ,&j PHONE: y— <br /> ADDRESS: At v`r t"w u Kf' c. tiJrt. bit,- <br /> CITY: <br /> CONTRACTOR'S NAME: LICENSE 9`115911H PHONE: 6-Q 4 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /- PUBLIC WATER WELL / / TEST WELL /- <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL j <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER4� <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 /> ACCORD WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF JOAQUIN, AND H ES AND REG LATIONS OF THE SAN JOAQUIN /LOCAL HEALTH DIISTRICT. <br /> SIGNED: CONTRACTOR:k�^+✓al iT+ff'l�/�o a tcG Cuc <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: �lk/,y-z, <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> (M"44,` ,dtP ',>3r" . ..",I r?,a'' `..r <br /> INSPECTION BY: DATE INSPECTION BY: ' ' DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT /72 1M <br /> DISTRIBUTION: ITE-HEALTH DISTRICT Y LLO�OPERT�N cINKO•NTRACTO �c <br />