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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. �I z <br /> (Complete in Triplicate) Date Issued; � �.! <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED 3 <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-RUL ES,AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> JOB ADDRESS/LOCA ON: Z CENSUS TRACT: f <br /> OWNER'S NAME': t .Ai/u C> PHONE: 2 i <br /> ADDRESS: U e• i�1���:, i s..... --- <br /> CITY: <br /> CONTRACTOR'9 NAME: LICENSE # 1 PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL i/�PUBLIC WATER LL / / TEST WELL /_ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /INDUSTRIAL WATER WELL <br /> 1;1y CATHODIC PROTECTION WELL / /_ GEOPHYSICAL_WELL / / OTHER <br /> 6 f'! 7 Vo c✓ r'%f pro E'f1.'a W C /4 C.c�4.) i✓v C 7­6L 1'} �1 i•. �� ��cz� l��-V C�%z Y <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES .0 PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD ,. CESSPOOL SEEPAGE PIT 12L� OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> f <br /> _J <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USE(:-"\ _ ._,. • .,.,.._ <br /> ell <br /> PLOT PLAN: SHOW ON REVERS SID <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 OFJOA I AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL TH DISTRICT: <br /> SIGNED: ? ,.�_.� CONTRACTOR: RossFul"'011igr'g- y11 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: A7. DATE: Z-- 7�s-- <br /> s <br /> ADDITIONAL COMMENTS: <br /> HASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY• DAT <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRI• 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> C <br />