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PERMIT N0. Z- <br /> APION FOR WELL OR PUMP PERMIT Issue <br /> " plete in Triplicate) <br /> FOR OFFICE USE: Date <br /> (Com <br /> THIS PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED Z- z z- 7 <br /> }, Op�—O`70-0/ <br /> 4.( 5-7Sl "oe- B7�f THE SAN FOR A <br /> PERMIT <br /> APPLICATIONGIS HEREBY MAD STO IOON N IS MADEAIN COMPLIANCE WITHCOUNTY ORINANCE FORM <br /> THE WORK STATED' HEREON. THIS APPLICAT <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN�JOA'QUIN LOCAL HEALTH DISTRICT. <br /> CENSUS TRACT: <br /> JOB ADDRESS/LOCATION: � � >� d=L PHONE: ' <br /> OWNER'S NAME: CITY: <br /> ADDRESS: PHONE: <br /> �f — <br /> ;� LICENSE O <br /> CONTRACTOR'S N <br /> INTENDED USE: INDIVIDUAL D ESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL / <br /> ' 4' IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> PROTECTION WELL / / GEOPHYSICAL WELPI / OTHER // <br /> CATHODIC U <br /> 4' =WELL: NCE TO NEAREST: . .SEPTIC TANK, SEWER LINES PIT PRIVX <br /> OTHERE DISPOSAL FIELD CESSPOOL SEEPAGE PIT <br /> REPAIRS: TYPE OF REPAIRS: <br /> - <br /> ' ABANDONMENT/DE5TRUCTICN: METHOD TO USED: ��£ _ <br /> f - <br /> n <br /> PIAT PLAN i SHOW ON REVERSE SIDE �� <br /> I` HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE <br /> WORK WILL;BE-DONE-IN <br /> OF <br /> E ORD <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS CP THE-STATE OF THE U CALIFORNIA,NjoTLOCAL HEALTHSDISTRICT. ' <br /> COUNTY OF, SAN JOAQUIN, AND THE RULES AND REGULA/TION <br /> CONTRACTOR <br /> SIGNED: <br /> h _ <br /> E ---- FOR-DEPARTMENT-USE'ONLY"" -; - --_ <br /> PHASE I i <br /> �— DATE: �sZ <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> . 7 ' <br /> - PRASE_III..FINAL <br /> DATE <br /> DATE INSPECTION BY: 4/ 1/72 <br /> INSPECTION BY. �, - <br /> E H 1426 IM <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> ;DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> - - <br />