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FOR OFFICE USE: T APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z <br /> (Complete in Triplicate) Date Issued: ? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9y7o7i <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. 053 '-0 yv—0`f <br /> fl�.�.. s, c7=v <br /> JOB ADDRESS/LOCA N:% ��� �' ,� , .' 'C 1$US TRACT: S47 <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: ± , CITY: <br /> CONTRACTOR'S NAME: ICENSE �� _PHONE- .,- � —!22� <br /> — <br /> i INTENDED USE: INDIVIDUAL DOMES- TC WATER WELL / / PUBLIC WATER WELL / / TEST WELL f� _ <br /> f IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELLINDUSTRIAL WATER WELL <br /> CATHODICC-PROTECTIONYELL GEOP.HYSICAL WEL 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: �FI <br /> r <br /> ABANDONMENT/DESTRUCTION: METHOD TO USED: <br /> If ! <br /> ! <br /> k <br /> k :PLOT-..PLAN.:4i�SHOW ONpREV-ERSE=SIDE =�;.a.. . .> T_ -, �..r .:�.....� _�--•---� <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 T FERULES ANDiREGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> jj99 <br /> SIGNED: A) CONTRACTOR: <br /> FOR-DEPAR ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS; `7 <br /> f <br /> PHASE II PHASE III FINAL —3f <br /> I � p <br /> LNSPECTION BY: DATE INSPECTION BY: - DATE ,�' -d 7 y <br /> E H 1426 '1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />