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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. CU <br /> (Complete in Triplicate) Date Issued: Z <br /> THIS 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 <br /> �, JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �'�3 fV AL. _G&�TUi � 14]-y�AO�CENSUS TRACT: <br /> OWNER'S NAME: - v FA PF' PHONE: <br /> ADDRESS: r ^A ;� CJ CITY: ACA fAAX D <br /> CONTRACTOR'S NAME: LICENSE # I2,7 1 PHONE: 3 6 - <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL ' POLICkWATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAP, WATER WELL / / INDUSTRIAL WATER WELL <br /> CLL ATHODIC PROTECTION WELL / / GEOPHYSICAL WE / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> Z <br /> 1 - <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 /> of - ✓1�(�-�' D <br /> /L�_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: 1 DATE: <br /> ADDITIONAL COMMENTS: A <br /> PHASE II PHASE 11 2FINAL <br /> INSPECTION BY: DATE 72- INSPECTION BY: z&' DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />