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,,7 � <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMA' PERMIT PERMIT N0. -7Z- ' Y 5 <br /> (Complete in Triplicate) Date Issued: 3_, (,.7-2 <br /> PERM - <br /> THI IT 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: 0 `/_ - �• CENSUS TRACT: <br /> OWNER'S NAME: fS &j PHONE: g0j Vn, 7g r? <br /> ADDRESS: Igo e F»S t CITY: jF&C q). )a <br /> CONTRACTOR'S NAME: T. 7j• v rte - �,�. ._ LICENSE # PHONE: <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 /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: oyB. - ►�f 7' }%'��1,4 -4, Re P1 'W) T 4 - <br /> !.? :a td 6, Pa, M 1? t� <br /> C� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 /> SIGNED: .�� „ „ - -------- CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: ( � Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION Bim` DATE INSPECTION BY: =�, DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />