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T <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT. \PERMIT NO. <br /> (Complete in Triplicate) Date Issued: .5-/5 7 �HIS 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 1 <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. z <br /> JOB ADDRESS/LOCATION: 3 O 0.3 f. YAJI M r R CENSUS TRACT: <br /> OWNER'S NAME: n t?r e 7L� JA_ PHONE: <br /> ADDRESS � 3 D ,f byc- !'i Ir'P - CITY: Q -el <br /> CONTRACTOR'S NAME: LCiVIP LICENSE # G' PHONE; G - <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL M PUBLIC WATER WELL / / TEST WELL / / - <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL %/ OTHER / F <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK O() SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> I REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED, <br /> PLOT PLAN; SHOW ON REVERSE SIDE f f <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 THESANJOAQUIN LOCAL HEALTH DISTRICT.. <br /> SIGNED: CONTRACTOR:"() <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> IV <br /> PHASE' II ---= _ PHA E III/FINAL- ! - - - <br /> ,! INSPECTION BY. DATE - INSPECTION BY le 11AWIDATE <br /> E H 1426 SAN JOA VIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />