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FOR OFFICE USE: CATIbg FOR 4LL OR PUMP PERMIT PERMIT NO. "72_- 2-V_ <br /> (Complete in Triplicate) Date Issued: _ p • <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 /> N0. 1862 AND RULES AND REGULATIONS.,,OF THE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> yi M t <br /> JOB ADDRESS/LOCATIOo e��io�` CENSUS TRACT: <br /> N: <br /> OWNER'S NAME: <br /> PHONE: 193/ • 407.16L_ <br /> ADDRESS: S / jP j 4L CITY: XJ�0 ck- r' <br /> CONTRACTOR'S NAME: LICENSE �!,13 '"PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL L 7 PUBLIC WATER WELL / / TEST WELL L7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /&_INDUSTRIAL WATER WELL /? <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL E/ 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: I7Gt L !1 Y t G •� <br /> Gl ra c 4-Z> a1�f' a 14 GC r& <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 /> COUNTYOF JOAQUIN, ES AND REGULA ONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> ,PHASE I <br /> 7 <br /> APPLICATION ACCEPTED BY: �'��4' J DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II E II FINAL <br /> INSPECTION BY: DATE INSPECTION DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTR 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER INK-CONTRACTOR <br />