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FOR OFFICE USE: A ,ICATION FOR WELL OR PUMP PERM PERMIT NO. -J <br /> \:1 (Complete in Triplicate) �'{ Date Issued: --7 y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> FILE <br /> COPY , <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: j (Q� py.w�-a. CENSUS TRACT <br /> OWNER'S NAME: M a 07 PHONE: 3(,A <br /> J 7 <br /> ADDRESS: CITY: <br /> CONTRACTORS NAME: LICENSE # Z-,-') PHONE: _ a[�-- j2 z <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL f ELL INDUSTRIAL WATER W /_/ <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL—/—/ OTHER <br /> NEW WELL: DISTANCE TO N SEPTIC TANK �GE <br /> I PIT" IVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL S T OTHER@� <br /> REPAIRS: TYPE OF REPAIRS: - ILL ` UAA C- <br /> 4 <br /> ABANDONMENT/DESTRUCT ON: MET OD TO BE USED: <br /> a <br /> a <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> i <br /> I HER Y CERTIFY THAT HAV —PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCO ANCE WITH THE P VISI NS OF LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUN OF SAN JOA UI , HE LES REGULATIONS OF THE SAN JOA UIN LOC DISTRICT. <br /> SIGNED: u= r. , 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 2-.2 .3-7:)_ INSPECTION BYc'-V- DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />