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OFFICE USE: ,:APPLICATION FOR WELL OR PUMP ]HERMIT PERMIT NO. 7L 4(S(Complete in Triplicate) Data Issued: 7 �I S% -72--,[FOR <br /> THS 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 DIST I_CT. <br /> C4!>A/ C,-r- P TS[ G--/ /✓V,,r&e 74 <br /> / �7�2_�wC <br /> JOB ADDRESS/LOCATION: /2) 7 SOW /^ CENSUS TRACT: <br /> OWNER'S NAME: 1 1.s 7r._ ONE: <br /> ADDRESS: �. CITY: A.L,Rr y <br /> CONTRACTOR'S NAME: Ad <br /> LICENSE _I t -3() HONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL-/-/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC -PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> n <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES /D47�PIT PRIVY <br /> SEWAGE DISPOSAL FIELD !Op 7`- ESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> v <br /> ii <br /> I � <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 <br /> ^LOCAL <br /> /HEALTH DISTRICT., <br /> CONTRACTOR: <br /> SIGNED: Vt <br /> ,ss 4.A*_&Lr - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY: <br /> " DATE 7 2— <br /> ADDITIONAL COMMENTS: Cv <br /> r PHASE III FINAL <br /> PHASE II j� .- <br /> INSPECTION BY DATE c�` ���-� INSPECTION BY s S -�2e-_9a DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />