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FOR OFFICE USE: "APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z,(Complete in Triplicate) Date Issued: zIT 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. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOC4,L HEALTH DISTRICT. <br /> JOB ADDRESS/LOC T ON: 47 CENSUS TRACT: 2�2- f70 ^3D <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: _ icy CkciklDbi 5 c CITY: <br /> CONTRACTOR'S NAME: u-yv% ,,os LICENSE # 2 3,7 PHONE: I2 S <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / IT PUBLIC WATER WELL /t;K TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> T <br /> NEW WELL: DISTANCTO N T' S ICT SE LINES IT IVY <br /> SEWAGE DI SAL FI ESSPOOL EEPAGE P 0 R ' w <br /> REPAIRS: TYPE OF REPAIRS: _ �� Sl e-yy\ Vl <br /> IN V <br /> f <br /> 9 <br /> n <br /> ABANDONMENT/DESUCTION: ME HOD TO BE SED: <br /> l <br /> k PLOT PLAN: SHOW ON REVERSE SIDE <br />{ I HEREBY RTIFY HAT I HAV PREP D THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDACE WIT T PROVISI NS THE LAWS OF THE STATE OF CALIFORNIA, THE ORDIN OF THE <br /> COUNTY OF SAN OA I , R LES AND REGULATIONS OF THE SAN JO INLOC ISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i <br /> APPLICATION ACCEPTED BY: _ _ DATE: <br /> ADDITIONAL COMMENTS: T <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: e'� DATE / <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />