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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES I 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 /> �.L <br /> JOB ADDRESS/LOCATION: 187.'7 E.' Hd- hway 120 _ CENSUS TRACT: _. <br /> OWNER'S NAME: Ed- VanEs _ <br /> _ - - PHONE: . 83_r 7875 - <br /> ADDRESS: ;..«.G <br /> - - - ---------- ---- CITY:- Ripon- <br /> CONTRACTOR'S NAME: .-;'John Pan- pro _ _ LICENSE # 1.20724 PHONE: 838-757n 886-5400 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL f7 PUBLIC WATER.WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL /? <br /> CATHODIC PROTECTION WELL ./.. / GEOPHYSICAL WELL f _/ OTHER <br /> _,NE W;WELL:, .DISTANCE-TO-NEAREST-:—SEPTIC TANK-L.1._ mSEWERLINES- �­PIT­PRIVY �"- <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER--,--__. <br /> REPAIRS: TYPE OF REPAIRS: A�U <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I <br /> 1 <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 PROVISIQAiS OF THE �LAW9 OF THE-STATE�OF CALIFORNIA; THE-'ORDINANCES OF-THE;L: <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> i <br /> . r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY: DATE: 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE <br /> EIH 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />