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FORT T A' '7aAC i 1ON FOR `�ZIJ, OR PU11P PERMIT ��_ItT�I`i. N0. <br /> (Camplete in Triplicate) DATE ISSUED: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED , <br /> APPLICATION IS HE MAiIE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM THE <br /> WORK STATED HEREAFTER. TRIS.�APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE NO. AND <br /> RULES AND REGULATIONS. <br /> JOB ADDRESS/LOCATION: i CENSUS TRACT: <br /> OW14ER°S NAME: I PHONE: -ADDRESS. --d 4 4 10 ---- CITY: <br /> CONTRACTOR': s NSE : u OL <br /> E: <br /> INTENDED USE: INDIVIDUAL STIC WATER TELL / PUBLIC WATER 1ELL f-7 TEST WELL �'! <br /> IRRIGATION/LIVESTOCK/AGRICULT[TR'ZWATER WELL /7 INDUSTRIAL LdATI;R C?ELL F7 <br /> CATHODIC PROTECTION WELL !/ GEOPHYSICAL WELL ®7 OTHER _ __- <br /> (PLOT PLAIN: SHOW SIZE OF LOT, LOCATION OF WELL IN RELATION TO SEPTIC SYSTEM, OTHER MEANS OF <br /> POLLUTION, ETC. SHOWN ON REVERSE SIDE). t, <br /> NEW WELL; 'DISTMCE-TO-HEOEST: 'SEPTIC TANK: �-:�- SEWEk-LIAS - _'.a. P�TaPR.T.V.y _,, SEWAGE-DISPOSAL <br /> FIELD CESSPOOL/SEEPAGE PIT �_OT€M MEANS O tLUTION-Si3RI� �]RAINAGE OR <br /> SUBSURFACE WHAT? - -- <br /> (WELT, DRILLER'S REPORT-FORM NO. MUST BE FILED WITH TIL, SAN JOAQUIN LOCAL HEALTH DISTRICT ON <br /> ALL 14EW OR RECONDITIONED WELLS). <br /> REPAIRS: TYPE OF REPAIRS: '. a <br /> 1 <br /> SEE RULES AND REGULATIONS FOR COVERING 14ELL AND DISINFECTING.SECTION ). <br /> ABANDON/DESTRUCTION: METHOD TO BE USED: __ - - �------ <br /> t(SEE RULES AND REGULATIONS REGARDING ABANDONMENT AND DESTRUCTION) . <br /> I HEREBY CEnTIFY THAT I HAVE PREPARED THIS APPLICATION AND-,THATTHE, WORK WIL BE DRE IN ACCORD- <br /> ANCE WITH SAN JOAQUIN COMITY ORDINANCES, STATE LAWS AND RULE:., ". R1'CULA'TIONS OF THE SAN JOAQUIN � <br /> LOCAL HEALTH DISTRICT. <br /> f CONTRACTOR: fJ' Y 'TITLE <br /> SIGNED: -�---��-�-_._.-_.--- - <br /> HO. i ..w FOLLOWING: ' <br /> III 4 CE. 7F•Y THAT 1No%.&' RF'ORMANCE OF VIE WORK FOR WHICH THIS PERMIT 19-ISS. UED,"�I SHALL NOT <br /> EMPLOY ANY PERSON IN SUCH 14ANNER AS TO BECOME SUBJECT TO WORKMAN'S COMYEIISATION '.AWS OF <br /> CALIFORN IA'I. <br /> SIGNED-. z BY TITLE: /} _ <br /> FOR DEPARTMENT -USE'.Ot,TLY <br /> D9fE <br /> APPLICATION ACCEPTED BY• � � �-�----- <br /> ADDITIONAL CO&IENTS: <br /> ^� FINAL VINSP-ECTION BY: 'i DATE: <br /> M^`-, SAN JOAQUIN LOCAL HEALTH DrISTRIGT <br /> 7/71 — 100 <br /> f , f <br /> i <br />