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OR OFFICE USE: AP CCATT, 0 -FOR-WELL--OR PUMP PERMIT PERMIT NO. L s <br /> (Complete in Triplicate) � Date Issued: <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j _ /. F <br /> 'PLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> IE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> iB ADDRESS/LOCATION: `(!, `i _ )'�� k=jai;{ - �_ CENSUS TRACT: <br /> TIER'S NAME: /.-• ( -4 ,-777-6--77 PHONE: G J <br /> )DRESS: S = / CITY: ..X <br /> )NTRACTOR'S NAME- : 4- LICENSE 11 PHONE:(TENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELLH TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL / J <br /> CATHODIC PROTECTION WELL // J GEOPHYSICAL WELL / / .OTHER / <br /> C-)r ` C/,i' �i-• �� 6ti ll/,r r.' L/-(- c, <br /> :W WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> _ SEWAGE DISPOSAL FIELD _ CESSPOOL SEEPAGE PIT _� OTHER 4. 1. <br /> :PAIRS: TYPE OF REPAIRS: )Ae,, l�.C- - ��Jc� , �' /4' Nl. c', (clr'i <br /> Ci. (ri.=-= \//,ff�J rr 1I6 i;.r/L/� �/C7-jra �fC 1 -l. ✓'(//-�':L�a.('/'� ,It 1/a.�r:.�/- . Gi s'. ysi: /�/. <br /> i.I! '� ^=�Gi•' L.L''(' p k:.l.(, \lV (I/tel lQ(� / / Lr- (. '/ �1. ll// /.L aL �• .L it G .-.`(i.�L- (�l� C(.`iJY'1'� / <br /> 3ANDONMENT/DESTRUCTION: METHOD TO BE USED: l ,t C! <br /> If ( 1 / nt �//� a //�//6`P C( L, � � r.` �c• -( ( t,�% C °�F' 'L� f ci.� 6i <br /> ! <br /> .OT PLAN: SHOW ON REVERSE SIDE <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> XORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> AUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HE4TH DIS 1ICT. <br /> CGNED: � �/., Y [% L h ` f CONTRACTOR: " <br /> FOR DEPARTMENT USE ONLY <br /> SASE I f <br /> PPLICATION ACCEPTED BY:� iyr�cr�Y`J _f._/ DATE: <br /> DDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> NSPECTION BY: DATE INSPECTION BY: r/' <br /> DATE <br /> H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 <br /> ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />