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' I <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: S- 8 -7-z-- <br /> THIS <br /> rTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY E 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. 22_S_ OfoO4��' <br /> JOB ADDRESS/LOCATION: _ J r_' GLANJaY-S7,- -' SC U A CENSUS TRACT: <br /> OWNER'S NAME: PHONE: - <br /> ADDRESS: G E CITY: S <br /> CM@RR; '@&'SNAME: LICENSE PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL / f _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELLEL <br /> _ /,/INDUSTRIALYWATER WL_/_/— �.�......{ <br /> CATHODIC-PROTECTIOJN WELL% / GEOPHYSICAL WELL L_1 OTHER <br /> . pus f GL N. c� <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> �- SI <br /> REPAIRS: TYPE OF REPAIRS: p� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USEDf <br /> r <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS;APPL!CATTON AND THATtTHE 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 JOA N, AND ES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY: DATE: S 6 12 7' <br /> ADDITIONAL COMMENTS: <br /> PHASE II P11ASE III .FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 . SAN JMWIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK--CONTRACTOR <br />