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FOR OFFICE USE: AP.� CATION FOR WELL OR PUMP PING111,... PERMIT N0. 2,- / L v <br /> (Complete in Triplicate) Date Issued: -3 - 17z- <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: G L, & V �. CENSUS TRACT: <br /> OWNER'S NAME: —r c{� / = PHONE: <br /> ?ADDRESS: CITY: <br /> CONTRACTOR'S NAME:- _fit -`L`�� y�� [c. �,�j_,�-(-ti.•, ayLICENSE # g-A j-ZL./ PHONE: ZZ <br /> INTENDED ' SE;`�':, INDIY.IDUAL DOMESTIC WATER WELL /A'7 PUBLIC WATER WELL / / TEST WELL _ <br /> � `. ` R�2IGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER _ /_7 <br /> VEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESiY00LFS EEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: 3jV rte{[.1_ 1 S <br /> CIO <br /> . n <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 'LOT 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 /> ;OUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: XCONTRACTOR: me-,IV/(Ii-41, *.y L� <br /> FOR DEPARTMENT USE ONLY <br /> 'EASE I <br /> APPLICATION ACCEPTED BY: _4DATE: 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL -'--. <br /> INSPECTION BY: DATE INSPECTION BY: !ice DATE 02 <br /> H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> )ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />