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FOR OFFICE USE: APPLICATION,FOR ,WELL OR PUMP PERMIT <br /> PERMIT N0. _ 51 <br /> " (Complete to .Trilleate <br /> �3v THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued: L. -7_Z <br /> APPLICATION IS HEREBY TO lilt `SAN iJOAQUIN LOCAL HEALTH Di STRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS 'APPtI'CATION 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':' CENSUS TRACT: <br /> OWNER'S NAME:NAME; �y <br /> ADDRESS: PHONE: <br /> CONTRACTOR'S NAME: CITY:` <br /> v4 J _� _ LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER: WELL. / / PUBLIC WATER WELL f_1 TEST. WELL /_7 j <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_/ INDU�§­TRIAL WATER WELL %f <br /> CATHODIC PROTECTION WELL/ GEOPHYSICAL WELL L_/ OTHER / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PR - <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT . OTHER ' IVY <br /> .i <br /> REPAIRS: TYPE OF REPAIRS: <br /> i t <br /> ABANDONMENT/DESTRUCTION: METHOD-TO-BE USED: <br /> -------------- <br /> D <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> Qom„ <br /> I HEREBY CERTIFY THAT I HAVi PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS- OF THE LAWS._OF THE-STATE-OF. CAL`IFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> r <br /> SIGNED: <br /> : CONTRACTOR: <br /> f� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> ' E <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: DATE: <br /> PHASE It PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY:,19222LDATE -al �- <br /> E Hx426 'SAN' JOA UIN-LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE-HEALTH DI.STRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR l/72 lM <br />