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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -Z S <br /> (Complete in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE 0 <br /> 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. e 4,S--z 'v--12 <br /> JOB ADDRESS/LOCATION: OAf LiAe,6 ,04IC f G LMNSUS TRACT: <br /> OWNER'S NAME: r 14,b / PHONE: 416,6 `6 S 71 -- <br /> ADDRESS: - Ufd CITY: 7 <br /> AN CAg- <br /> CONTRACTOR'S NAME. LICENSE #-46 7 61 PHONE: 46 U 9 f 3� <br /> F <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK W " SEWER LINES tg�OL PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER W <br /> OP <br /> REPAIRS: TYPE OF REPAIRS. _�1/S G �`Y -2 C <br /> 1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: A <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> THAT I HEREBY CERTIFY <br /> T T 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 /> 6.1 <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -,qL <br /> APPLICATION ACCEPTED BY: 0� - d - cl„ DATE: ? / 7 L <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: _ DATE -,3- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />