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FOR OFFICE USE: r i PLICATION FOR WELL OR PUMP PERMIT PERMIT NO. `7 Z=/' 7, <br /> �f, (Complete in Triplicate) Date Issued: <br /> 11HIS 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 /> 44773 ,c1 . W. -(-�A,d -,Dr i d?t _3!0. -3 D <br /> JOB ADDRESS/LOCATION: 2 luile S. Comstock-8001 Ni. Cox CENSUS TRACT: <br /> OWNER'S NAME: Pete. M. Brgman PHONE: 478-595oADDRESS: 23 N. E Dorado St . Stockton Calif......, CITY: S*.ockton <br /> CONTRACTOR'S NAME: F ry .ance Drillers LICENSE #2/+0107 PHONE: x;31- 6$ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL , / PUBLIC WATER WELL /�/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / -/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK lCO' SEWER LINES - 1001PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> \N <br /> Z <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 /> COUN JO. AND THE RULES AND REGULATIONS OF THE .SAN JOAQUIN LOCAL TH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: -7 � z22 ca cJ _ DATE: A_�2L y <br /> ADDITIONAL COMMENTS: <br /> PHASE II EV W4/FINAL <br /> INSPECTION BY: DATE -� -{I INSPECTIONON ,. 11TE <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DIS -- 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELL0U-P 0,PF-ft'QY 014Nie; TOg <br />