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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: I <br /> 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 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: r�lyi a/ S' Rte'I"ig/ yid CENSUS TRACT: <br /> OWNER'S NAME: PHONE: 6 r� <br /> ADDRESS: CITY: g A` 7- <br /> CONTRACTOR'S <br /> CONTRACTOR'S NAME: cf��y/!f/ ''R v �� �c-r LICENSE # xj$-Z6 PHONE: c!4 <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL /_/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> / %f <br /> CATHODIC PROTECTION WELL J GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 'f!„— SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: 5 YA L z- F 5 U, �L'/$�- IV e' <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I <br /> i y <br /> i <br /> i <br /> i <br /> PLOT PLAN: SHOW ON REVERSE..SIDE <br /> rf <br /> R <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: <br /> + CONTRACTOR: !'. Gc.• �' S .ys � <br /> R 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I� <br /> APPLICATION ACCEPTED BY: r (5r DATE: <br /> ADDITIONAL COMMENTS: <br /> i <br /> PHASE II PHASE III/FINAL 4 { <br /> INSPECTION BY: DATE INSPECTION BY: DATE _ , — /Q• 7 1',L <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />