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FOR OFFT_CE USE: y <br /> 'LTCATION FOR WELL OR� PUPIL' Pl%RMIT_ PERMIT NO. <br /> (COmplete in Triplicate.) <br /> THIS PERMIT EXPIRES I YEAR FROM DAj'E ISSUED late Issued-:77-7- =_ <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 WITII COUNTY ORDINANCE <br /> iO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: ya <br /> OWNER'S NAME• &All �1�y 4 - on, CENSUS TRACT; <br /> ADDRESS: L PHONE: <br /> rr 7 <br /> R' <br /> CONTRACTOS NAME: L o CITY: <br /> ,`:- LICENSE # ;c c �'. <br /> E 3 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / _INDUSTRIAL WATER WELL /__f <br /> CATHODIC PROTECTION WELL / f GEOPHYSICAL WELL /_7 OTHER / 7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 9 0,1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PITC OTHER <br /> REPAIRS: TYPE OF REPAIRS: ✓ /Vl--VV r_-a,>4--G/ _ <br /> N <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: _ m <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 SANQU N, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: , CONTRACTOR: . <br /> - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: / DATE: 3J -7-L <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL'--'-- <br /> INSPECTION BY: - DATE !L� '> -- INSPECTION BY• DATE ---- <br /> 3 H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT T _ 1/72 1M <br />)ISTRIBUTION: , WHITE--HEALTH DISTRICT — YELLOW—PROPERTY OWNER -- PINK—CON':,'RACTOR <br />