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OL w F Sf Tm6 - CJ <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: 3. 2,-1,. <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: ,FO h MURN4CENSUS TRACT: <br /> OWNER'S NAME: UNT_9>e "r-Loa PHONE: <br /> ADDRESS: 1_ CITY: <br /> CONTRACTOR'S NAME: /yj S P,Q,S• LICENSE # PHONE: _ <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL /N TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _TNDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> r -, <br /> REPAIRS: TYPE OF REPAIRS: 498 WEI- ` <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: Z <br /> t - <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> k <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WI THE PROVISIONS OF THE LAWS OF THE STATE .OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF J AQUIN, AND THE. ULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 9 <br /> APPLICATION ACCE DATE: <br /> ADDITIONAL COMMENTS: <br /> 14 <br /> PHAS II FINAL <br /> INSPECTI N BY: DATE INSPECT_BY ZL4&VDATE -Z/ Zai <br /> E H 1426 .,SAN-JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR ( j <br />