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FOR OFFICE U E: APPLICATION FOR WELL .OR PUMP PERMIT PERM-IT NO::' '7�^ Z b <br /> (Complete in Triplicate) Data Issued: <br /> T I5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO ''THE Sh,N-`JOAQ�JIN 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: _ CENSuS TRACT: <br /> ? S' L7 'I j <br /> OWNER'S NAME: PHONE: 9eS_,2SI *Y <br /> ADDRESS: d. ' CITY: FSc�qZd1✓_ -- <br /> CONTRACTORS NAME: LICENSE # PHONE. _ $fig'_ a.2o-x <br /> INTENDED USE: INDIVIDUAL DOMESTIC -WATER-WELL•/:PUBLIC-WATER WELL / / TEST WELL L7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / f GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> I <br /> I <br /> REPAIRS: TYPE OF REPAIRS: 4- l A S 7"// <br /> 3W41? <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> S <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 /> FOR DEP TMENT USE ONLY <br /> 14 PHASE I <br />` APPLICATION ACCEPTED BY: �J DATE: <br /> ADDITIONAL COMMENTS: 'k <br /> PHASE II PHASE III FINAL <br /> INSPECTION, BY: "w DATE <br /> INSPECTION' <br /> DATE. <br /> ... <br /> E H 1426 T SAN-JOA UIN LOCAL HEALTH DISTRICT . 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER- PINK-CONTRACTOR <br />