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E FOR OFFICE USE: APPLICATION FOR WELL OR FUMP PERMIT PERMIT N0. L_ -2-:7 0 <br /> (CompleL in Triplicate) Date Issued: <br /> i S PERMIT 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 LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: <br /> OWNER'S NAME: MIZ PHONE: y L w .22 <br /> ADDRESS: -2 I r f CITY: SG !a <br /> CONTRACTOR'S NAME: E - ":� F LICENSE_#m PHONE: _yC-2- ,1-,--7 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL J// <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: <br /> M <br /> . � <br /> - F <br /> ABANDONMENT/DESTRUCTION: METOD TO BE USED.: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS IIAPPLICATION 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, THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR:+ , <br /> c <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 57 <br /> APPLICATION ACCEPTED BY: + �' DATE: �f <br /> ADDITIONAL COMMENTS: :Ip: <br />' PHASE ,II PHASE -III/FINAL . <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 : SAN JOAQ]III T;OCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />