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FOR OFFICE USE: APPL CATION FOR WELL OR PUMP PERMIT PERMIT NO. 2Z V� <br /> (Complete in Triplicate) Date Issued: <br /> l.� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO!kRFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINA$CE <br /> NO. 1862 AND RULES ANDREGULATIONS 0 THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �P � A L. AriTCl9 CENSUS TRACT: �` S <br /> OWNER'S NAME: D0M1W1 3__A tioiyd Alvd .5_X; Z& M_ 4ag".et PHONE: 632 1 ytj7 <br /> ADDRESS: / la /fox S/t /hi G u /if: CITY: <br /> CONTRACTOR'S NAME: G0ACICA .0^://:ala Go_ LICENSE #lo6737 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L_1 OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK/O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> fi <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 RULM <br /> AID REGU TIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: - CONTRACTOR: <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE: <br /> ADDITIONAL COMMENTS: to <br /> ti <br /> PHASE II II FINAL <br /> INSPECTION BY: ® DATE (?"74- INSPEC B ATE -Z5 <br /> E H 1426 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DiISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />