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FOR .OFFICE USE: ADPL CATION FOR WELL OR PUMP PERMIT PERMIT NO. z 2 4 <br /> (Complete in Triplicate) Date Issued: 2-S-72, <br /> THIS PERMIT EXPIRES `1 YEAR FROM DATE ISSUED <br /> r <br /> APPLICATION IS HEREBY MAD 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 /> f NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: (a �o [�L- - -- CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: _ - -- <br /> CONTRACTOR'S NAME c ` !�,,w. ` �„� �r1. `a, LICENSE # I,eg .j 7 PHONE- 4A4 . M,25—__ <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 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: .6 <br /> i <br /> - 6 <br /> i <br /> r <br /> s A <br /> ' ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE` SIDE <br /> r <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 <br /> }'REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: h� j7.�Jyu x f �ti���t��?1 rr _ CONTRACTOR: i <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> f APPLICATION ACCEPTED BY: a DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION B"� DATE rl 7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRI1/72IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />