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FO$„ OFENE USE: APPLICATION FOR WELL OR TUMP PERMIT PERMIT NO. <br /> (Complete' ln Triplicate) Date Issued: <br />` THIS PERMIT EXPIRES 1 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 /> NO. 1862 AND RULES AND REGI T'IQNS 0OF � SAN JOAQUIN LOCAL H LTHDISTRICTa <br /> JOB ADDRESS/LOCATION Eq,p l e of -Tu r by Just South o f CENSUS TRACT: s <br /> OWNER'S NAME: John Bo arini 1 `'os PHONE:447- <br /> ADDRESS: I West, 6wairl CITY• oc 5an, <br /> CONTRACTOR'S NAME: John'-Panero LICENSE 4 PHONE:83-P-7570 88 6-5 00 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / J PUBLIC. WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /x/ LL <br /> _INDUSTRIAL WATER WE <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER II <br /> r <br /> REPAIRS: TYPE OF REPAIRS: + <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED <br /> F P, <br /> f e <br /> f ro <br /> 0 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> - <br /> i HEREBY CERTIFY THAT I HAVEPREPAREDTHIS 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: ! <br /> CONTRACTOR: <br /> r <br /> PHASE I FOR DEPARTMENT USE ONLY - <br /> `` ' • <br /> IS <br /> APPLICATION ACCEPTED BY: DATE: .� <br /> ADDITIONAL COMMENTS: <br /> .ate•`v o/ 6~' <br /> PHASE II PHASE III FINAe <br /> INSPECTION BY: DATE 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 />