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PERMIT NO. Z- <br /> FOR OFFICE USE: _ADPL TION�FOR. WELL OR PUMA?p,ERM1 Date Issued: 3 I <br /> (Complete 'in .Tr#licate) - <br /> S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> A.pERMT TO <br /> APPLICATION IS HERE Y MADE TO� THE SAN �JOAQUIN LOCAL HEALTH DISTRICTFOR <br /> COUNTY ORDII3ANCEERFORM <br /> THE WORK STATED HEREON. "-THIS APPLICATION IS MADE IN COMPLIANCE -�O <br /> N0. 1$62 AND RULES AND REGULATIONS OF THE SAN JOA QUIN LOCAL HEALtH' STRICT. <br /> 2-0 n� � ' I �F CENSUS TRACT: <br /> o f��i) onr ��� �w p d�erz PHONE., <br /> ` <br /> JOB ADDRESS/LOCATION: CI E., — <br /> OWNER'S NAME: GG �R �� PHONE: 3 <br /> ADDRESS: S `I4 - u LICENSE /I <br /> CONTRACTOR'S NAME: C r'I SIG-6/ <br /> PUBLIC WATER WELL �/ - TEST WELL �� <br /> INTENDED USE: INDIVIDUAL DOMESTIC_WATER WELL I�I _INDUSTRIAL WATER WELL II <br /> IRRIGATION/LIVESTOCK/AGRICULTURAOPSWATICAL WELL / OTHER __._ <br /> CATHODIC PROTECTION WELL L_1 <br /> 3 <br /> t <br /> NEW WELL: DISTANCE TO NEAREST: SEI CFS-SNKPOOL� EEPAGE� PTT <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> ESiOTHER � <br /> { REPAIRS: TYPE OF REPAIRS: l1111 !� <br /> l- <br /> ,i <br /> 4 t <br /> i <br /> -T0 <br /> ABANDONMENT/DESTRUCTION: METHOD-TO-- <br /> C <br /> s <br /> E <br /> t PLOT PLAN: SHOW ON REVERSE SIDE i <br /> f <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION <br /> PTH.EAS AT AND CALLIFORRNNIA, THORK EORDINANCES OF THE <br /> ` ACCORDANCE WITH THE PROVISIONS OF THE LAWS <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR: <br /> SIGNED: <br /> I <br /> FOR DEPAR <br /> a ENT USE ONLY <br /> PHASE I I �'7� � <br /> I �J DATE: <br /> APPLICATION ACCEPTED BY: <br /> 3 ADDITIONAL COMMENTS: <br /> PHASE III FINAL <br /> PHASE II <br /> INSPECTION BY: DATE <br /> INSPECTION BY: DATE _ 1/72 3M <br /> E H 1426 . SAN JOA UIN LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE-HEALTH +DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR - <br />