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FOR OFFICE^ USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: 'v <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS H REBY 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 /> o--o--c- S. .4 / r p o r f uJ a 7 <br /> JOB ADDRESS/LOCATION: SRZ4"7•elN N //j POf?7' CENSUS TRACT: <br /> OWNER'S NAME: U PHONE: <br /> ADDRESS: ' A 22 jAll eEfF CITY: pe,N BM_ <br /> CONTRACTORS NAME: 114Aff-AL W-I'L L 4 LOL V IP CG, LICENSE # t O PHONE: 9G2- 6--0 7 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL f / PUBLIC WATER WELL /—/ TEST WELL /- _ <br /> IRRIGATION/LIVESTOCK Yom'/AGRICULTURAL WATER WELL INDUSTRIAL WATER WELL/ / <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 OTHER LA <br /> t <br /> e <br /> REPAIRS: TYPE OF REPAIRS: 1P <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW 0N 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 PEALTH DISTRIC . <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ _Q' <br /> APPLICATION ACCEPTED BY: �' f��'�YW DATE: • '3 - y <br /> ADDITIONAL COMMENTS: <br /> PHASE PHASE III FINAL <br /> INSPECTION BY: Ad DATE INSPECTION BY: e10 DATE s /8 ?/ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT — 1142 1M <br /> DISTRIBUTION: WH TE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />