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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z- Z, 5 Ti <br /> (Complete in Triplicate) Date Issued: L <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. <br /> I ), c •✓ C f <br /> JOB ADDRESS/LOCAT ON: L ,0 of t ` A aENSUS TRACT: <br /> OWNER'S NAME PHONE: s'3191-is P <br /> ADDRESS: S4 jw6 _ CITY: r� <br /> CONTRACTORS NAME: 3 ei Al -• LICENSE # PHONE: - <br /> INTENDED USE: INDIVIDUAL :DOMESTIC WATER WELL /& 'PUBLIC WATER WELL /_/ TEST WELL /_ _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_/ LL <br /> YINDUSTRIAL WATER WE <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> k <br /> REPAIRS: TYPE OF REPAIRS. Zr <br /> - •---•— S <br /> Ilk <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 1 <br /> r <br /> PLOT PLAN: SHOW ON REVERSEISIDE 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 THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH,DISTRICT. <br /> SIGNED: - CONTRACTOR: <br /> I FOR DEPAR ENT USE`'ONLY k J <br /> k PHASE I .� <br /> APPLICATION ACCEPTED BY: .V 2of,. � . <br /> DATE: <br /> ADDITIONAL COMMENTS. <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: �� DATE INSPECTION BY: Q,. DATE 7-6-70, <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />