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OR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. G Z I <br /> (Complete in Triplicate) Date Issued: 4.13.17 <br /> THIS PERMIT EXPIRES 1 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: + n ido a4' ljgg 'Rond I bgi=Ren Tiirnpr._. CENSUS TRACT: <br /> OWNER'S NAME: PHONE: 6 446$ <br /> Robe- <br /> ADDRESS: _ 3-93-05 'No Rater Rna.i_ - CITY: Lodi s CAUE0 _ <br /> CONTRACTOR'S NAME. swn LICENSE # 271800 PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMES"TIC WATER WELL f_1 PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELIKJO�- INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL / / OTHER <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: Drill 12" Well <br /> Middle Of Vineyardp 4 " <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 /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: C m Inc CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: -.j6-7 <br /> ADDITIONAL COMMENTS: f <br /> PHASE II P1jASf III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE ' a�2 <br /> E H 1426 SAN- JOAQUIN LOCAL HEALTH DISTRICT_ 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW--PROPERTY OWNER -- PINK-CONTRACTOR <br />