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FOR OFFICE USE: APPLICATION FOR WELL OR P15MP PERMIT PERMIT NO. Z2,--1 0/ � <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY E 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 /> ,FOB ADDRESS/LOCATION: <br /> ION: 4099 S. KAISER RM STKN. , CA. CENSUS TRACT: - <br /> OWNER'S NA[��E: PHONE. <br /> ADDRESS: Og .` bh . CITY: <br /> CONTRACTOR'S NAME: /E' 11(/� 4,aI ' C LICENSE # � PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / % PUBLIC WATER WELL / / TEST .WELL <br /> IRRIGATION/LIVESTOCK/AGRTCULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL %/ OTHER / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 100=-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 5_,?P/CESSP00L SEEPAGE PIT OTHER' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> NM. <br /> r <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: C.cE CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE I F <br /> 1 APPLICATION ACCEPTED BY: DATE: / 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> _�PAe _ INSPECTION BY: DATE 7 2� <br /> ` INSPECTION BY: DATE <br /> IM <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRIC I/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PI -CONTRACTOR <br />