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AOR OIiEICE USE: APPLICATION 1A4R WELL OR PUMP PERMIT PERMIT N0. y p <br /> (Complete in Triplicate) Date issued• r-. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> -7-7- <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 WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 21f f Sa. %/ Tli c—,--ra^1E <br /> JOB ADDRESS/LOCATION: �.t` ' CENSUS TRACT: <br /> 00-7 /Q� �( <br /> OWNER'S NAME: ,t r r PHONE: <br /> ADDRESS: - A &_LkAM_ � CITY: <br /> CONTRACTOR'S NAME. st LIt:1ENSE # PHONE: - <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /? PUBLIC WATER WELL El- TEST WELL L7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL INDUSTRIAL WATER WELL / 7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL OTHER <br /> NEW WELL.: DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES PIT PRIVY <br /> SWAGE DISPOSAL FIELD CESSPOOL:SELPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> I,� <br /> r - <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: &Tc fL �A(r ;,� O Ci trF r�. .• <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 JOAQUIN' AND THE RULES AND REGULATIONS OF THE.SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED. ONTbR <br /> _ 7RLAAC <br /> S " y <br /> -- DEPARTMENT USE ONLY-- - <br /> PHASE a FOR D - • - - <br /> APPLICATION ACCEPTED BY: DATE: ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL, <br /> INSPECTION­BY: DATE .mss_ INSPECTION BY: DATE <br /> Y••— <br /> E H 1426 <br /> SAN JOA UIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />