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IC-6 <br /> FOR OFFICE USE: AP: CATION FOR WELL OR PUMP PERMIT PERMIT NO, zy <br /> v(Complete in Triplicate) Date Issued: - 7 �v <br /> S 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. 't <br /> JOB ADDRESS/LOCATION: IVY12- E LOUD j F CENSUS TRACT: 7 <br /> OWNER'S NAME: nIng —J, iv \144,� 176 PHONE: <br /> ADDRESS: / gl'f]oZ �- 1.n 1/,S& R . CITY: <br /> CONTRACTOR'S NAME: T/� S„ l, , ¢ S'o� LICENSE 11 PHONE: S} ?k Zp7 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /ZT-PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER// p <br /> REPAIRS TYPE OF REPAIRS: Adj sS ' pf fin/ Z/Z 32-7 T <br /> N <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: I <br /> C <br /> U� <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: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: A'0 DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />