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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 2)?- G17� <br /> (Complete in Triplicate) Date Issued: 3 -/- 7y <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> ` J <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 /> JOB ADDRESS/LOCATION: ; �1=i- .��. CENSUS TRACT: <br /> + PHONE: <br /> OWNER'S NAME: �,-_ � . � � _ <br /> ADDRESS: JfCITY: / <br /> CONTRACTOR'S NANg: <br /> c Y Gei�c- LICENSE # I PHONE:LL et_ <br /> f.�• r' ��CC t <br /> INTENDED_ USE: INDI A� ME�IAW1T�R WELL PUBLIC WATER WELL / / TEST WELL /-7 — <br /> IRRIGATION/LIVESTOCK/AGRICUL L WATER WELL / / INDUSTRIAL WATER WELL I / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL, / / - OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J9 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ;4-2 CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: vv <br /> in <br /> o ` <br /> - <br /> �� O <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> } <br /> PLOT PLAN: SHOW ON REVERSE .SIDE <br /> k- t <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN-- <br /> ACCORDANCE WITH THE PROVISIONS OF TIJE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF-THE <br /> COUNTY OF SAN JO IN AND THE R L AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: i r I�� - CONTRACTOR: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY: / eJ DATE: ` <br /> ADDITIONAL COMMENTS: - u <br /> PHASE II Y PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: - DATE ;3-_7-_ �1-•- __ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT ' e' 1/72 114 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK�CONTRACTOR <br />