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FOR OFFICE, USE: A7PLICATION FOR WELL OR PUMP PERMIT- PERMIT NO. <br /> r (Complete in Triplicate) Date Issued: Jj <br /> YREBY <br /> i HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION MADE 'TOTHE 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 /> ,J 0- S. 41 , po rf W a y <br /> JOS ADDRESS/LOCATION: S7azIr78N A //'r PORT CENSUS TRACT: <br /> OWNER'S NAME: 0 v PHONE: <br /> ADDRESS: 222 G, �'.BE/? / CITY: OG.f' ON <br /> CONTRACTOR'S NAME: P�A?/( kA✓EL L 4 66i v!P GG, LICENSE # � PHONE: G2' + J <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /—/ PUBLIC WATER WELL /—/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSTRIAL WATER WELL /_7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL SEEPAGE PIT _ OTHER _ LU <br /> REPAIRS: TYPE OF REPAIRS: c c <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 j7TH DISTRIC . <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �7 <br /> APPLICATION ACCEPTED BY: if d3 • �J,J-��/ DATE: 3 • 3 • qv <br /> ADDITIONAL COMMENTS: <br /> PHASE PHASE III FINAL <br /> INSPECTION BY: / DATE INSPECTION BY: E/p DATE .S-/D 1-7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/42 IM <br /> DISTRIBUTION: WH TE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />