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FOA OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. ' '7 Z,-2- ::5 q <br /> (Complete in Triplicate) Date Issued: 4— '- 7 Z: <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: 957.j,y. A CENSUS TRACT: <br /> OWNER'S NAME: PHONE:3. <br /> ADDRESS: Lodi Calife. <br /> CITY: <br /> CONTRACTOR'S NAME: Gr)ahring;Well Dri;l_l`: LICENSE #� PHONE: .9483 P.O. Box: 61:6 Lockeford, Calif <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL / _ <br /> IRRI N/LIVESTOCK AGRI ,Uf� L WATIIt WELL � INDUSTRIAL WATER WELL <br /> DIC OTECTION WELT/ GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES ins PIT PRIVY <br /> SEWAGE DISPOSAL FIELD I.5()t- CESSPOOL SEEPAGE PIT -OTHER'T�t Tell pit 20 deep. <br /> REPAIRS: 'TYPE OF REPAIRS., NONE` Neer 101 Pell <br /> E <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: I <br /> i <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 QUIN, AND THE LES AND #EGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT.. <br /> SIGNED: CONTRACTOR IGOOhri ng, Well Drilli , <br /> f FOR DEPARTME USE ONLY <br /> PHASE I <br /> 2-1 <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: «� � <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE �' INSPECTION BY: DATE <br /> E H 1426 SAN- JOAQUIN 'LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR9- <br />