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.-rn c 6 n y <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br /> 4Se)CzlVo I <br /> E <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. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION �� �rtoarr'1��7 U.Y'cU '00; CENSUS TRACT: °C <br /> OWNER'S NAME: - PHONE: <br /> ? C�.0 gTr"�as�f^.6•� + <br /> ADDRESS: !`r <br /> r� CITY: <br /> CONTRACTOR'S NAME: - o:+s LICENSE # PHONE: zf <br /> it <br /> ,INTENDED USE: INDIVIDUAL .DOME$STIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> -'± CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / I OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 04 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> va <br /> e Iw F� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> ;I <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> VE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> I HEREBY CERTIFY THAT I HA <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE LES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR: <br /> SIGNED: I <br /> FOR DEPARTMENT USE ONLY I! <br />. PHASE I � � <br /> DATE: <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL �� <br /> -'ISATE �f <br /> INSPECTION BY: DATE INSPECTION BY: '�� _ <br /> IM <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW--PROPERTY OWNER — PINK—CONTRACTOR <br />