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OFFICE USE• � ' ` <br /> FOR APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> Z ' ' (Complete in Triplicate) Date Issued: _3-L3. 7 L <br /> THIS PERMIT EXPIRES 1 YEAR ,FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE 0 THE SAN OAQUIN 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 /> LOCA ON: (.'� MLC L I - CENSUS <br /> TRACT: t -- l eO-2,1-) <br /> OWNER'S NAME: N e- PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE ?PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /ELL/ _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDU TRIAL WATER W / / <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL / / OTHER <br />-NEW WELL:- -DISTANCE TO NEAREST: SEPTIP. TAN EWER LINES �[0 PIT PRIVY No-Le <br /> SEWAGE DISPOSAL FIELD 7-M CESSPOOL SEEPAGE PIT)j4ff0THER -,f&.jq i <br /> REPAIRS: TYPE OF REPAIRS: <br /> ' I <br /> i <br /> ABANDONMENT/DESTRUCTION: -METHOD TO BE USED: ' <br /> PLOT. PLAN: SHOW ON REVERSE' SIDE <br /> t- I-HEREBY-CERTIFY"THAT'-II-HAVEYPREPARED-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. i <br /> SIGNED: - � t / lLGG/ i�'� ,(I��� ONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: <br /> DATE: <br /> ADDITIONAL .COMMENTS: _ <br /> &AV,4= <br /> PHASE II PHASE III FINAL � <br /> INSPECTION BY: � DATE INSPECTION BY: DATE S -\15 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DI_STRI_C 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR •y G <br />