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FOR OFFICE USE: vw.LICATI.ON FOR WELL OR PUMA S?I f"11".' PERRY N0. ? � <br /> "'Complete in Triplicate) Date Issued: <br /> L --- THIS PERMIT EXPIRES I 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 /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> J Ob ADDRESS/LOCATION: CENSUS TRACT: <br /> OWNER'S NAME: —r, j l=l s PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: Y1411-:2 S AL ?4c & 2 { S<<, , LICENSE # ;46 5-7&/ PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WAFER WELL �� PUBLIC WATER WELL / / TEST WELL /'_j _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUS'£RIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEP'wIC TANK _ SEWER LINES PIT PRIVY <br /> .SEWAGE DISPOSAL FIELD CESSPOOL PAGE PIT OTHER <br /> REPAIRS:: TYPE OF REPAIRS; /`✓ '; Zit l- l_ 5 <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 DONE IN <br /> "iCCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> SOUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED. CONTRACTOR: rC•�✓1�/.,•-/�,'ifr�� fJ t. .>1?� a•<<,.,,�CC <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY: DATE: 3 <br /> 4DDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: lig=' DATE <br /> H 1426 SAN JOAQUIN LOCAL HEALTH_DISTRICT 1/72 1M <br /> )ISTRIBUTION: ,WHITE–HEALTH DISTRICT – YELLOW–PROPERTY OWNER -- PINK–CONTRACTOR <br />