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APPLIC T N FOR WELL OR FUMY` PERMIT PERMIT NO. <br /> FOR OFFICE USE• Date Issued: c _ c - 7?— <br /> _ (Complete in Triplicate) <br /> T IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MARE 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 /> JOB ADDRESS/LOCATION: - F Q CENSUS TRACT: . ` <br /> OWNER'S NAME: I� LL L — PHONE: ! - <br /> a CITY: Gf�L. ��CRtr <br /> ADDRESS: a PHONE: <br /> CONTRACTOR'S <br /> CONTRACTOR'S NAME: %rrtrl.� LICENSE 4� z <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL <br /> CATRODIC PROTECTION WELL / / GEOPHYSICAL WELL %/ OTHER <br /> L <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK (,p ' SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL-SEEPAGE PIT OTHER" <br /> f <br /> REPAIRS: TYPE OF REPAIRS: <br /> C <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> E <br /> �. PLOT PLAN: SHOW ON REVERSE SIDE <br /> i <br /> t 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 /> 'J <br /> CONTRACTOR- <br /> SIGNED: pct u <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I /J <br /> APPLICATION ACCEPTED BY: / J BATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE IlPHASE III/FINAL' <br /> INSPECTION BY: DATE <br /> INSPECTION BY: DATE-/ <br /> 1J72 <br /> E H 1426 ! . SAN JOAQUYN LOCAL HEALTH_DISTRICT <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT — YELLOW-PROPERTY OWNER PINy%_CONTRACTOR <br />