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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMITPERMIT NO. -/ <br /> -31 <br /> (Complete in Triplicate) Date Issued:/ yr 7L. <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISS D <br /> 2-v0 -0-- <br /> APPLICATION <br /> -0-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 /> elf qLt� j_A_C10 6,c Al!) 11 1 b 1 <br /> JOB ADDRESS/LOCATION: 42 <br /> 42d, CENSUS TRACT: <br /> OWNER'S NAME: N ;, _ PHONE: <br /> ADDRESS: E0CITY: <br /> CONTRACTOR'S NAME: LICENSE # 142J PHONE: �6 x,57 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER"WELL f/ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUWELL STRIAL WATER WL /_/ <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE T ST: SEPTI TANK SEWER LIN PIT RkIVY T <br /> SEWAGE DISPOSAL- D CES SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> 1 <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 /> SIGNED: G1.ff-h=jeCONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: L2 I,' <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE 2JA7 <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH_DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />