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tl <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT <br /> PERMIT NO. �- <br /> (Complete 3n Trip.licate). Date Issued: sz� <br /> HIS 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 REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. + <br /> JOB ADDRESS/LOCATION: 24666 E. Naripo sa` <br /> OWNER'S NAME: Ronald. Higginbotham CENSUS TRACT: <br /> ADDRESS. same PHONE; 8 3 <br /> CONTRACTOR'S NAME: CITY: Escalon <br /> LICENSE #1 20Tc)hn Pah E_ 724 _ PHONE: 838-7570 -776--5-400 . <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /_/ PUBLIC WATER WELL /_/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAI. WATER WELL )C_1_INDUSTRIAL WATER WELL <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 <br /> REPAIRS: TYPE OF REPAIRS: Clean sand from old 121" well "' ' <br /> ell. , <br /> in <br /> ABANDONMENT/DESTRUCTION:METHOD TO•BE USED: <br /> s�4 <br /> ` y <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THATI HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OFI'HE STATE OF CALIFORNIA, THE ORDINANCES OF THE i <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- <br /> By:' /Ct- ♦ <br /> ADDITIONAL COMMENTS: <br /> DATE: <br /> PHASE II Ay <br /> PHASE III FINAL <br /> INSPECTION BY: DATE -- INSPECTION BY: DATE ' f ^7 v <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />