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FOR OFFICE USE: APPLICATION FOR WELL OR PUMA' PERMIT PERMIT NO. I <br /> ' _ (Complete in Triplicate) Date Issued: g- 1• � Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t j f <br /> APPLICATION IS HERZMADE TOTHE 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: �-6 o 9 CENSUS TRACT: b <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: slog. -0� CITY: Ccs.. <br /> CONTRACTOR'S NAME: .. LICENSEd&g-/�;-8y PHONE: .G Y- i/hyo <br /> t <br /> f3!r J „a..�ror _ <br /> INTENDED USE: INDIVIDUAL DOMEST C WATER WELL "PUBLIC WATER WELL /f TEST WELL /_7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE LIT OTHER <br />` REPAIRS., TYPE OF REPAIRS: <br /> b <br />' ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> .Sr <br /> C 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: �.a.L � �� CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4 APPLICATION ACCEPTED BY: r DATE: �1Y7 Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II SE III/FINAL <br /> INSPECTION BY: DATE /INSPECTION BY: DATE <br /> F E H 1426 1 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />