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' FOR OFFICE vsE• <br /> APPLICAtWq.FOR WELL OR PUMP PERMIT PERMIT N0.' IZZ - q6 <br /> (Complete in Triplicate) Date Issued: 'Z_ 1 _7z, ' <br /> T IS PERMIT EXPIRES' l YEAR FROM DATE ISSUER ! <br /> i <br /> 1 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: 0 3 �,�, (w ¢/amu CENSUS TRACT: <br /> OWNER'S NAME: a qz!� PHONE: <br /> - ADDRESS: Ca 3 , P CITY: o <br /> CONTRACTOR'S NAME: NSE #Zp(n PHONE: ; — <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / J PUBLIC WATER WELL / / TEST WELL / J <br /> -IRRIGATION/LIVESTOCK/AGRICULTURAL=WATER WELL /74- INDUST-RIAL-WATER WELL, <br /> % -/-- <br /> CATHODIC PROTECTION WELL /_/ GEOPHYSICAL WELL / / OTHER f J/ <br /> t <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br />{ <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: , <br /> C <br /> I� <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> r <br /> i <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 CAL'rFORNIA,) THE ORDINANCES OF THE <br /> T-COUNTY.OF.SAN-JOAQUIN, .AND_THE R.ULES_AND_REGULATIONS OF THE SANnI QUIN L AL�LTH DISTR CT. <br /> �.�� A <br /> .,,. <br /> SIGNED: �� � CONTRACTOR.• <br /> FOR DEPARTMENT USE ONLY k <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II <br /> PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY•�j bk�DIR DATE 3 - 3c) — ] . <br /> E H 1426 . SAN JQ_AQUIN LOCAL HEALTH DISTRICT 1/72 1M , <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />