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FOR OFFICE USE: '?' APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. :Z `' -7 <br /> (Complete !in Triplicate) Date Issued: <br /> THIS 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: E• Hildreth .Lane , CENSUS TRACT: <br /> OWNER'S NAME: Dr. & Mrs. Ii. ffuscagllrlPHONE: 477 41�8 <br /> ADDRESS: _ 710-'Mae Duff Ave. CITY: Stockton � <br /> CONTRACTOR'S NAME: J. 'A, Thalhamer Cop LICENSE # 272303 PHONE: 477 l <br /> 859 <br /> WATER WELL PUBLIC WATER WELL / / TEST WELL /7 _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC. f'/ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL .WATER WELL / f INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICALW�LL-, /' / OTHER / / <br /> NEW WELL: # D I STANCE TO NEAREST: SEPTIC TANK 150 f 9FWW LINE5 I IT PRIVY € <br /> �. SEWAGE DISPOSAL FIELD 150 ftGESSPOOL SEEPAGE PIT OTHER �^ <br /> REPAIRS� TYPE OF REPAIRS: <br /> I <br /> 1 � j <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> ll k. <br /> PLOT PLAN: SHOW ON- REVERSE SIDE 4 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCt WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF . AN JOAQUIN, AND THE RULES AND REGULATIONS,'& THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> �I N <br /> SIGNED: CONTRACTOR: <br /> '�'�`��� . <br /> CT <br /> f t > FOR DEPARTMENT USE ONLY <br /> PRASE I { <br /> APPLICATION ACCEPTED BY: DATE; <br /> ADDITIONAL' COMMENTS: .. <br /> r - <br /> r PHASE II P E III/FINAL <br /> INSPECTION BY: DATE INSPECTIeNBY.`(A' <br /> DATE <br /> E H 1426 - . SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />