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FOR OFFICE VSE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. ­� Z-Z 6 C7 <br /> (Complete in Triplicate) Date Issued: <br /> T\HI EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM i <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. 0 2,ko—12— <br /> ADDRESS/LOCATION <br /> I2ADDRESS/LOCATION: L?�¢/(/y� % / �c� a/i/, s�p CENSUS TRACT: S <br /> OWNER'S NAME: 4. G y� � 14 • /� PHONE <br /> ADDRESS: ! d.� � i& 2 116 - s6 7I,_,., l <br /> C c CITY: <br /> CONTRACTOR'S NAME: &R-9 77 4 LICENSE # 472303 PHONE: 3 (j ZZ 'f <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL /—/ TEST WELL /_7 __. <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> REPAIRS: TYPE OF REPAIRS: <br /> 4 y <br /> ',ITSI <br /> r• <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> • <br /> PLOT PLAN. SHOW ON REVERSE SIDE <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 /> 4 <br /> SIGNED: ! CONTRACTOR: <br /> / c <br /> FOR DEPART ENT USE ONLY f <br /> PHASE I j <br /> APPLICATION ACCEPTED BY: DATE: lv�el_ 72_ <br /> ADDITIONAL COMMENTS: <br /> - tPHASE II . PHASE III FINAL <br /> INSPECTION BY: DATE s INSPECTION BY: - DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR `' <br />