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' FOR OFFICE USE: <br /> APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 2,-1 5-0 <br /> {Complete in Triplicate) Date Issued: 3 =? <br /> HIS 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/LOCAT ON: `1 - CENSUS TRACT: _ S11 _ <br /> OWNER'S NAME: S -h7 Tg.•:-- i4O� r � - --- PHONE: ; <br /> ADDRESS: - CITY: gZ94�:�'' <br /> CONTRACTOR'S NAME: + 1w t4o, LICENSE # 117 Z / PHONE: <br /> er 6 =-�5� <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / ./ TEST WELL <br /> IRRIGATIO L'Tt►•SSPcfA _ WATER WELL 22 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f / GEOPHYSICAL WELL / / OTHER <br /> � r <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 300 SEWER LINES JOW SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT —_OTHER <br /> REPAIRS: TYPE OF REPAIRS: -J <br /> •� a <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: � �'t� /> /�/I/•_.ysy�, �� <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: CONTRACTOR: <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY: ��' - DATE: -/ - 7 ?/ <br /> ADDITIONAL COMMENTS: <br /> ' � r <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: <br /> DATEf <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />