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FOR OFFICE USE: jT <br /> PPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' 172-- <br /> (Complete <br /> Z - Z <br /> (Complete in Triplicate) Date Issued: _]Y <br /> PERMIT EXPIRES 1. YEAR FROM DATE ISSUED V f 7 3 �1 <br /> APPLICATION TS HEHE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br />� , THE WORK-:STATEDwHPPLICATION-.IS MADE�IN-COMPLIANCE WITH•._COUNTY.._ORDINANCE <br /> N0. 2862 AND RULEONS OF THE S ON LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCAT ON: <br /> CENSUS TRACT: <br /> . OWNER'S NAME: PHONE: 6�-c5`3ti' <br /> ADDRESS: CITY:NS -- <br /> CONTRACTOR'S NAME: LICE <br /> �EQ'�_ ,r�� PHONE: 36 4.16 yo <br /> INTENDED USE: INDIVIDUAL DOMES' C WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL- WATER WELL / /_INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL / / GEOPSICAL WELL / f OTHER / J <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS., TYPE OF REPAIRS: # `1 r c.J <br /> 4 �s <br /> • <br /> S <br /> L <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> .t-moi I ....--'+w• .e•++�.. .ra .. • �T:• � _ '— 'L �s _ <br /> 1l 4 .� <br /> 1 } <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 /> COUNTYTQF MR JOA QUIN,;-,AND�THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED N CONTRACTOR <br /> y 1 <br /> FOR DEPARTMENT USE ONLY i <br /> f PHASE I i <br /> 0 i <br /> APPLICATION ACCEPTED BY: n $. DATE: <br /> ADDITIONAL 'COMMENTS: <br /> PHASE II PHASE IIT FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE:/ "`` ' <br /> E H 1426 v SAN JOAQUIN' LOC-ALHEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> V\ <br />