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FOR OFrICE USE: APPLICATION FOR WELL, OR PUMP PERMIT PERMIT NO. 7 2-- 3 5 7 <br /> (Complete in Triplicate.). Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> • y <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATEDHEREON. 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: Funck Rd. , Farmington CENSUS TRACT: <br /> OWNER'S NAME: Artie Go rdo n PHONE: 866_540b <br /> ADDRESS: 2231 Funck Rd. CITY: Farmington <br /> CONTRACTOR'S NAME: John Fanero LICENSE ff 120 724 PHONE: 838-7570 886-5400 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /T/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAG PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: 161" new i�el l <br /> P <br /> ABANDONMENT/DESTRUCTION: METHOD TOED: <br /> tt <br /> PLOT PLAN: SHOW ON REVERSE SIDE <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: CONTRACTOR <br /> I - <br /> FOR DEPARTMEN USE ONLY ` <br /> PHASE I _ _ - <br /> APPLICATION ACCEPTED BY: �i r DATE: /172- <br /> ADDITIONAL COMMENTS: _- --- � _ ✓ ^'x� + v. i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />