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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. � Z-�Y <br /> (Complete in Triplicate) Date Issued: - jl/. <br /> HIS FERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> APPLIATION 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 /> ��S <br /> JeS/LOCAT ON., tsar C - 1.11'-��„WCENSUS TRACT: <br /> OWNER'S NAME: 14 st L'le 'e,4 ► ZP HONE: <br /> ADDRESS: 1 r CITY: <br /> CONTRACTOR'S NAME: '. x ,LICENSE _ PHONE <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL f_1 <br /> CATHODIC PROTECTION 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: } L�-:r Al 4. k, <br /> I <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: p <br /> 1 Y0�j <br /> TEN SYS f EMS <br /> PLOT PLAN: SHOW-ON- REVERSE SIDE <br /> 526' PALO nAaVIF QE,—UK <br /> 478-7179 <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: ,r CONTRACTOR:. <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: Ci DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQU7[N_LOC_AL HEALTH DISTRIC 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR J <br />