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FOR OFFICE USE: (--.'?LICATION FOR WELL OR PU14P PERA ) PERMIT NO <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PE011ToPERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY i'K�e.�E: <br /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> .TOB ADDRESS/LOCATION: - <br /> ef.a u� 4 F R c � � CENSUS TRACT: <br /> OWNER'S NAME- -Z;, " 1�its }-L-::fes, •_ PHONE: <br /> ADDRESS: :L 4 ef At L G R CITY: <br /> CONTRACTOR'S NAME: , / -yeA SA i-.p jy t� , _4 p/y4ICENSE # ;Z65- <br /> 7!i PHONE: y <br /> INTENDED USE: INDIVIDUAL D01ESTIC WATER WELL PUBLIC WATER WELL f_1 TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—// INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK Ahad SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> k <br /> REPAIRS: TYPE OF REPAIRS: Af S T A L`- j / " Gc. Al P � <br /> 4b <br /> . rS <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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: Fi. CONTRACTOR: f a tj h °r fz S AL f�i c Ai <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: —1 ' � <br /> ADDITIONAL COMMENTS: <br /> PHASE I PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 7 S-AN_ JQAQUIN_LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />