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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ;�2- <br /> (Complete in Triplicate) Date Issued: Z.2 7z <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. , 390 I,gj CENSUS TRACT: S `T <br /> OWNER'S NAME: •1/c - 1/ - ]' PHONE: <br /> ADDRESS; - •�'� J <br /> CITY: _ <br /> CONTRACTOR'S NAME: C v �` r LICENSE PHONE: /7 f <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 f / GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL DISTANCE TO NEAREST: SEPTIC TANK 7SAEWER LINES �? ' PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> t <br /> REPAIRS: TYPE OF REPAIRS: <br /> C� <br /> 0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: l <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 /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: 9, CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: /;Z /7.2_ <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE L-17' 72 <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR w wd'. <br />