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FOR OPF CE USE: APPLICATION FOR WELL ORPUMP PERMIT PERMIT N0. Z 1 5 5 <br /> (Complete in Triplicate) Date Issued <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 JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: 1 zr 4 ij•,r 411 en Z P c i In—^. CENSUS TRACT• 5` <br /> JWNER'S NAME: _ Ra , -nd C ;sic pit, r PHONE: <br /> ADDRESS: » n 'ar- n� t1'' V CITY: �:�.,^T'?,i'.:n o <br /> IONTRACTOR S NAME: J^hn F nnr,ro LICENSE 1 ^� ? PHONE: -5 4n0 <br />(INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL L PUBLIC WATER WELL / / TEST WELL L-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL /-7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 1 -0'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> kEPAIRS: TYPE OF REPAIRS: <br /> r <br /> oC) <br /> c� <br /> yBANDONMENT/DESTRUCTION: METHOD TO BE USED: _ <br />'LOT PLAN: SHOW ON REVERSE SIDE <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> CCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br />,OUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> i <br />'IGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY: . T-%((A,27j"V y\, DATE: <br /> DDITIONAL COMMENTS : <br /> PHASE II PHASE III FINAL l_ <br />-NSPECTION BY: f1 �� DATE ' z�' 7 INSPECTION BY: i -L� DATE <br /> If 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />