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FOR OFFICE USE: CAPPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. - 5 <br /> Complete in Triplicate) Date Issued: Zv <br /> T EXPIRES 1 YEAR FROM DATE .ISSUED <br /> APPLICAT'10N IS HEREBYE 10 THE SAN JOAUIIONQISNMADE INH <br /> LOCALHCOMPLIANCE WI'FHEALTH DISTRICTFCOUNTY ORDIINANCEERFORM <br /> THE WORK STATED HEREON. THIS APPLICAT + <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: %S 6 p +Al e 7.7.4 13 `7 40"Mrop g j,,,r.*&t S�TRACT: <br /> PHONE: 44 -q! <br /> OWNER'S NAME: C.17_0 Lc.. 0 CITY: S' I g Al ' <br /> ADDRESS: ¢ LICENSE # PHONE: L��re r <br /> CONTRACTORS NAME: lwNlI/ A <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 /> i <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK '149 o"SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER i <br /> � e <br /> REPAIRS: TYPE OF REPAIRS. <br /> O <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <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 /> f <br /> SIGNED: + r) CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> { DATE: Z <br /> .APPLICATION ACCEPTED BY: C. <br /> ADDITIONAL COMMENTS: ;1 <br /> PHASE II i PHASE III/FINAL <br /> 67 - 79- <br /> INSPECTION BY: MATE INSPECTION BY: DATE "" <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 ]M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />