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-�T <br /> I ' <br /> r' : FOR OFFICE USE:' • APPLICATION,FOR WELL OR PUMP PERMIT PERMIT N0. 7��3[q <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �p <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 LOCAs, HEALTH DISTRICT, <br /> JOB ADDRESS/LOCATION: � --- �i� /� CENSUS TRACT: <br />�. OWNER'S NAME: G S PHONE: <br /> ' <br /> ADDRESS: �N <br /> CONTRACTOR'S NAME: —+ CITY: <br /> /+f a fL4�„-1 ICENSE aC.c� PHONE <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL f PUBLIC WATER WELL /% TEST WELL /-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /%_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> _ R <br /> NEW WELL: DISTANCE TO NEAREST; SEPTIC TANK jg CD 'SEWER LINES PIT PRIVY l <br /> •. SEWAGE DISPOSAL FIELD V ' CESSPOOL SEEPAGE PIT OTHER' I <br /> REPAIRS: TYPE OF REPAIRS: .' <br /> s•” A i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: r <br /> PLOT PLAN: SHOW ON REVERSE SIDE - C <br /> T � <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 TTE, STATE,,OF •CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND T E_ U REGULATIONS OF THE SAN� JOAQUIN LOCAL IiIS CT. <br /> SIGNED: ��-C� f CONTRACTOR!: f Ura f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> r � <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: DATE: <br /> PHASE II - r .,� = : ' PHASE ''III/FINAL <br /> INSPECTION BY: DATE !` ,INSPECTION BY: DATE Z — <br /> E H 1426 � � + <br /> SAN JOAQUINLOCAL HEALTH DISTRICT 1/72 1M . . <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY. OWNER — 'PINK—``CONTRACTOR- r—� <br />