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FOR OFFICE USE: APPLICATION FOR WELT, OR PUMP PERMIT PERMIT NO. `] L- Z B. <br /> (Complete in Triplicate) Date Issued: � • 71 <br /> THIS 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'Nor+hGst-_c�o�rnE_r o l�uaphy_& French TRACT: Zo3- Z� <br /> � <br /> OWNER'S NAME: She rkLo o d Fran c-e ll.a _ _—_-- PHONE: 9 2�0 570 <br /> ADDRESS: 19711 5. 12ue Rd CITY: Ripon <br /> CONTRACTOR'S NAME: __ John Panes LICENSE #12072 PHONE: 838-7570 6-5400 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL C1 PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /x/ INDUSTRIAL WATER WELL f_1 <br /> LL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WE /_/ 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: <br /> i <br /> i <br /> t ABANDONMENT/DESTRUCTION: METHOD TO BE USED: � <br /> I <br /> i <br /> I PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORKWI L L E DONE IN <br /> B <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 DEPARTME T USE ONLY <br /> PHASE I <br /> .APPLICATION ACCEPTED BY: ,/ DATE: <br /> .ADDITIONAL CO NTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE "" INSPECTION BY: f t/ DATE j/ 77-- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR "�°' <br />