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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -72 Z Z_ `J <br /> (Complete in Triplicate) Date Issued: c r�-l� <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 /> JOB ADDRESS/LOCAT N: Lc�i� ' l ry,•�e CENSUS TRACT: O 1? -2.t0 --/ Z <br /> OWNER'S NAME: PHONE: o <br /> --ADDRESS: .�`�Iv" CITY: <br /> CONTRACTOR'S NAME: LICENSE #/G Z 3 PHONE: 3 C.E3 �.-. <br /> l 3' �,5 _ _ <br /> U E INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /_7 _ <br /> U IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL Zy INDUSTRIAL WATER WELL / / ' <br /> -� CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> �WE `- I�TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> GE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' i <br /> R AIR: TYPE OF REPAIRS. <br /> 1 <br /> ABANDONMENT/DESTRUCTION>:.—METHOD.-TO-BE-�USEDa <br /> s <br /> I <br />'. PLOT PLAN: SHOW ON REVERSE SIDE <br /> - - i <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: x CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: G'o DATE <br /> E H 1426 ; SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M. — <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT — YELLOW—PROPERTY OWNER -- PINK—CONTRACTOR <br />