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FOR OFFICE USE: Ar ',IC T N FOR WELL OR PUMP PERMI' PERMIT NO. <br /> (Complete in Triplicate) ✓ Date Issued: y. cJ 7 Z <br /> ITIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <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: l/p !70 t I- t R T`� R D CENSUS TRACT: 'J i <br /> OWNER'S NAME: W1 LL 12 61 E PHONE: <br /> ADDRESS: 44 ! ti[3c'g _r L) CITY: 6,14 <br /> CONTRACTOR'S NAME: j� LICENSE 11_ILL2 7 6 i PHONE <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / LL <br /> INDUSTRIAL WATER WEJ / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK P/1-SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: N S TAI iO hp S tL 6 .Z/V X l S 7 IV -Zr e LG. <br /> c <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 /> 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: / i CONTRACTOR: rt.u6C�iid¢.1/-..•�� `'�ka° <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y �� <br /> APPLICATION ACCEPTED BY: ( _ J p� 7 �� �ii tte-LC, ✓/, I DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: � d DATE y'.Z/ -7 -2-- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />