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FOR OFFICt USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 2--i O <br /> (Complete in Triplicate) Date Issued: �= 3 7 Y <br /> Till's PERMIT 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 SEATED 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: 'J Q tr If," o-r CENSUS TRACT: <br /> OWNER'S NAME:o�a.+i k, hq",-"1 ` -W.-�r- - ��to�� f 1 �, !_ `�� <br /> PHONE• �- 9 7�7 <br /> ADDRESS: .3 D 0izk :�< CITY: <br /> CONTRACTOR'S NAM lam LICENSE # PHONE: $E d A-91, 4 S <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /-7 _._. <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /%—INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / / <br /> :NEW WELL: DISTANCE TO NEAREST: SEPTIANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES L SEEPAGE PIT OTHER ' <br /> I REPAIRS: TYPE OF REPAIRS. ___ ,Q � �h:,,. , ,_�, .,.. _� - C�rL =-• <br /> --------- ----- <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE U Q <br /> Q: <br /> a <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> orb . <br /> I HEREBY CERTIFY THAT I HAVEIPREPARED 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 /> E COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR. <br /> i <br /> # <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: / l�C� '1�9 ✓ d BATE: <br /> ADDITIONAL COMMENTS: s <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY. DATE _ INSPECTION BY: %,:t-9 kyo p DATE ), J ISS 7-1_--__ -_ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTR_IC_T 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />