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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. �o7-8'd <br /> (Complete in Triplicate) Date Issued: <br /> XTHIS 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 SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: ` /` �' le 4 r` v� CENSUS TRACT: <br /> OWNER'S NAME: ! h�-� b�/r n,ct _ PHONE <br /> ADDRESS: _ / r2a kgs _ CITY: s C.'Z- <br /> CONTRACTOR'S NAME: A/ Z_,W LICENSE # qa 7A� HONE: (16 l-- `PG 7L <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC .WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / 7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / L // GEOPHYSICAL WEL / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> CAt <br /> REPAIRS: TYPE OF REPAIRS: <br /> S rl o /d �nr�i6/ a_m-) roma lv�a <br /> U �.C12-7u ra► <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 /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTYOA IN, AND-THE RULES AND EGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 5 iGNID: L �d �- CONTRACTOR-: �`,,UI`"NL-.../ f _� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> k INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1 2 1M <br /> DISTRIBUTION: WHIT -HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />