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FOR OFFICE U`SE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: ,a _i - <br /> IS 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. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> .TOB ADDRESS/LOCATION: la kS � ��IL <br /> OWNER'S NAME: D_ J r4PHONE: <br /> ADDRESS: 1.L' t V�a+f 1?If Ju T:d CITY: F5c Ayk4- *1 <br /> CONTRACTOR'S NAME: _` . 4c,:iz hJ r ,c,�,t/ �. LICENSE # PHONE: 9-P c i <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /—/ PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /lf INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER F7 , <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: _po J R ' e)- /'4 C G &2Wj&S - jqj d <br /> l U Ari A/ O D j4.e i v Yi b 1 ive 1v me <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> C <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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT BY: DATE: ��-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIx FINAL <br /> INSPECTION BY: DATE INSPECTION BY: ,� DATE ___ - � -- <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR '` <br />