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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z-5 v J <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. T IS 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: g SUS TRACT: S yl <br /> OWNER'S NAME: j PHONE: ag 3 ;Z7 <br /> ADDRESS: LI a sLT 41, CITY: <br /> ' CONTRACTOR'S NAME: ICENSE # PHONE: <br /> INTENDED USE: INDIVI I1AL .DOMESTIC-WATER -WELL -/ /. PUBLIC WATER-WELL-/ / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL- WELL f_1 <br /> INDUSTRIAL WATER WE /_/ <br /> CATHOD,I�C..PROTE�CTION WELL'./ / ,GEOPHYSICAL WELL / / 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: x a C~1-pJ <br /> ABANDONMENT/DESTRUCTION:­METHOD'TO BE..USED:-- - -�- <br /> . 7C <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. i <br /> SIGNED: ' CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTED BY: DATE: e 'p / �' 77-- <br /> ADDITIONAL COMMENTS: <br /> .PHASE 11 PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT `, 3/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR I <br />