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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. - Z � <br /> (Complete in Triplicate) Date Issued: c�,Z <br /> T IS 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: Southca.q_t corner Narcis-SUS & St. Jo SUS TRACT: S` <br /> OWNER'S NAME: Carl D e g e rm a.n PHONE: - <br /> ADDRESS: 197-56 St. John CITY: Esca,lon <br /> CONTRACTOR'S NAME: . John Fanaro LICENSE #17777— PHONE: - F00 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /—/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_7 INDUSTRIAL WATER WELL _7 <br /> l CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 75 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> ^41% <br /> REPAIRS: TYPE OF REPAIRS: <br /> . Va <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 NONE 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: l _ ��P�rd CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ,.� DATE: L- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINALAl <br /> _rwr <br /> t m <br /> INSPECTION BY: t -0 DATE 74-7 INSPECTION BY: DATE J�O z Z� <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />