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i <br /> FaW,-OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: <br /> 1 /�HIS_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 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 /> Woodbridge <br /> JOB ADDRESS/LOCATION: a't GolfCourCENSUS TRACT: <br /> OWNER'S NAME: Lloyd costa PHONE: <br /> ADDRESS: P, 0. Box 417 . Woodbridge _ CITY: W odbridge _ _ <br /> CONTRACTOR'S NAME: VA Joaguin•",Pomp Cg=M y, _Ino_,__ LICENSE # 71800 PHONE' _ 369-8471_ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL El PUBLIC WATER WELL / / TEST WELL f_1 i <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL / / OTHER / / <br /> II <br /> l <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: Drill =11 150t <br /> � W <br /> • 1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> A. <br /> o- <br /> PLOT PLAN: SHOW ON REVERSE SIDE f <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: San Joa Cin Ptuc►p CMp=y# It1cr CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> I <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: ATE S-3- 7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />