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^f <br /> ' FOR OFFICE: USE:� ''JLICATION FO't I.F-iL OR PU'.! PI-IL-11T .'f F f PERMIT NO. ]_' <br /> -'.•rorplcte in Triplicate) Date Issued: 3 - 7 , <br /> THIS LXPIRES I YEAR FROM DATE ISSUED <br /> AFPLICAT1ON IS HEREBY MADE TO THE SAN JOAQJ/IN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> HE WORK STATED HEREON. THIS APPLICATION IS MADE IN CO`PLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULITIONS 0" THE SAN J)AQUIN LOCAL HEALTH DISTRICT. <br /> 'OB ADDRESS/LOCATION: 1. ._• Y"- <br /> CENSUS TRACT: <br /> OVNER'S NAME: _ �� PHONE: <br /> ADDRESS: r,ITY <br /> ` •J4 r! <br /> CONTRACTOR'S NAME: —,� /' LICENSE F J,�.JPHONE: 1.4 r(7� <br /> INTE.'.'DED USE: INDIVIDUAL DOMESTIC EATER 1.rLL / / PUBLIC WATER WELL ITT TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICUL'fUP•AL WATER WELL /—/_INDUSTRIAL WATER WELL <br /> �i,!HODIC PROTECTION WELL / / GEOPHYSICAL. WELL / / OTHER <br /> ` NEW (WELL: DISTANCE'.,TO NEAREST: SEPTIC TANK SEa'ER LINES _ PIT PRIVY <br /> SLWAGE DISPOSAL FIELD ,^.PSSPOOi. SEEPAGE PIT OTHER <br /> J :'FAIRS. TYPE: OF REPAIRS. <br /> R.. ---��_—. .ice— —/-�--�.–a.l 1 q F :l' I 1 �/ [' I / •--- ` t"�4 `� �_' <br /> EANDONMENT/DESTRIICTION: METHOD TO RE USED: <br /> 1 . <br /> i,.'.\: SHOW ON 1 D <br /> CE:RTJFY THAT 7 11VE 1 KE-PARED '1HIS APPLICATION AND THAT THE WORK VILL BE DO.:E I.': <br /> LITH THE PROVISIONS OF THE LE.WS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF TIC ' V <br /> :.;,': .1OAQUIN, A::D THE RUT ES AND REGULATIONS OF THE St.N JOAQUIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR: <br /> AOR DEP:,RR!ENT L'SE ONLY � q <br />