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FOR OP*FICE USE: APPLICATION R WELL OR PUMP PERMITPEfiMIT N0. >z- � o <br /> (Complete in Triplicate) Date Issued• -THISPERMITPERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Z__Z_z-1z___ <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 ICOMPLIANCE WITH COUNTY ORDINANCE <br /> N <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 21 ( 6, ", . _-rAc-rvti� l <br /> JOB ADDRESS/LOCATION: ff, .Z / - /�� l t` CENSUS TRACT: 00-7- /? -i f <br /> OWNER'S NAME: ,i �, e PHONE: <br /> ADDRESS: t •'�� r. r, r; J CITY: <br /> CONTRACTOR'S NAME. LIGENSE # p PHONE: �/- <br /> 1 _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL f_1 TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTUiRAL WATER WELL _INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL.: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Y <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> 7111. <br /> r _ <br /> REPAIRS: TYPE OF REPAIRS: >-i�{' ✓-,D � -!_��G� ` �,.%=C �.�� �A <br /> zj <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <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 THE .SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNEDc or ONTRACTOR: <br /> — <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION-'BY: DATE INSPECTION BY: DATE 7-3-7 <br /> E H 1426 SAN-JOAQUIN_LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />