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FOR OFFICE USE• <br />PLICATION F R WELT, 0R PUMP PERMIT PERMIT NO.-) — l._ <br />(Complete in Triplicate) Date Issued:� <br />THIS PERMIT EXPIRES I.YEAR FROM DATE ISSUED <br />APPLICATION IS HEREBY MAD 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,-, <br />OWNER'S NAME': <br />ADDRESS: <br />CONTRACTO S NAME: //--7.P- 7`1W Z <br />`%r <br />,If// � ,f -40,/ [if/Fl/ ,bill /, <br />INTENDED USE: INDIVIDUAL:DOMESTIC WATER WE' <br />IRRIGATION/LIVESTOCK/AGRICUL' <br />CATHODIC PROTECTION WELL /-7 <br />CENSUS TRACT: <br />- PHONE: <br />CITY: <br />LICENSE # PHONE: <br />PUBLIC WATER WELL /—/ TEST WELL /% _ <br />RAL - WATER WELL / / INDUSTRIAL WATER WELL <br />GEOPHYSICAL WELL / / OTHER /-7 <br />NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK D SEWER,,LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELDCESSPOOL SEEPAGE PI-TJLHER <br />r .r <br />REPAIRS: TYPE OF REPAIRS: <br />ABANDONMENT/DESTRUCTION: METHOD TO BE USED: t; <br />y6 t <br />A( <br />PLOT PLAN: SHOW ON REVERSE SIDE <br />I HEREBY CERTIFY THAThI 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. 4 <br />CONTRACTOR: v <br />PHASE I'Js �� FOR DEPARTMENT USE ONLY <br />4 I <br />APPLICATION ACCEPTED BY::' <br />ADDITIONAL COMMENTSSx{: <br />3 3 <br />INSPECTION BP--WRITE- <br />DATE' <br />E H 1426 -'SAN-JOAQUIN <br />DISTRIBUTIONLTH DISTRICT - YELI <br />INSPECTION BY: <br />HEALTH DISTRIC <br />PERTY - OWNER <br />4 - <br />DATE: 3,Z --- Z <br />INAL <br />� "ATE -- - � <br />1/72 ].M <br />