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FOR OFFICE USE: \ APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. S �� <br />� {Complete in Triplicate} Date. Issued: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <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 /> N0. 1862 AND RULES AND REGULATIONS OFTHE SANcr <br /> JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS JI OCATION <br /> 9 P t alideOf � r by 111st South Of CENSUS TRACT: <br /> OWNER'S NAME: John Bo Far n! Nan os PHONE: 447-966-7 <br /> ADDRESS: 11 Sprain CITY: Stockton <br /> CONTRACTOR'S NAME: Jahn Panero LICENSE # L2o32�— PHONE: 8 ,3-757Q sz 6_54QC <br /> INTENDED USE: INDIVIDUAiL DOMESTIC WATER WELL / f PUBLIC WATER WELL / / TEST WELL / J <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /�/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL J OTHER <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 /> ry <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 /> SIGNED: CONTRACTOR: <br /> FOR'DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATEt /'j <br /> ADDITIONAL COMMENTS.- v <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 f SAN JOAQUIN LOCAL_ HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />