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f <br /> K <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' 7,? $5� <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT`EXPIRES 1 YEAR FROM DATE ISSUED 7— 7 <br /> APPLICATION IS HEREBY MADE TO HE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON:' - TH PPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND RE 'LAT ONS OF THE SAN JOAQIJIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: Z'_ �J� �rr_`!'/ lip r �„�'�P! CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> j ADDRESS: CITY: 5 <br /> CONTRACTOR'S NAME: L / ^�� , LICENSE # �p PHONE: r <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 / / GEOPHYSICAL WELL ,/ OTHER <br /> 1 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SE—JEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REP IRS: G(/ /�(! 10 <br /> 21, <br /> w <br /> r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 77.i;�� � ja/ � <br /> t <br /> t <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 T. E RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: -� t CONTRACTOR: �r - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I q <br /> APPLICATION ACCEPTED BYa,, <br /> �C1< DATE: <br /> Ltci" <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: 'AVIDATE ?-,/2- <br /> E H 1426 SAN JOAQUYN LOCAL HEALTH DISTRICT . 1/72 .1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />