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FOR OFFICE USE: APPLICATION FOR WELL OR TUMP PERMIT PERMIT NO. . z-Z'o <br /> (Complete,in;Triplicate) Date Issued: <br /> ' 11,S 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.`LOCHEALTH DISTRICTi <br /> . .� stir t zr w AL <br /> a . no rw CENSUS TRACT <br /> JOB ADDRESS/LOCATION: O 7 <br /> OWNER'S NAME: PHONE:ice- SG <br /> ADDRESS: S - y ,. .. .. . .,. - - CITY': <br /> CONTRACTORS NAME: �. '' LICENSE # -r PHONE:; Z.P,,? _ <br /> INTENDED USE: INDIVIDUAL,DOMESTIC-WATERWELL./,�TPUBLIC-WATER WELL - TEST WELL-/ / <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: f� �! pG' 01�/ l % /��' QST fly m p _ <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ' <br /> 1 <br /> r <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> t <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATIOIC 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: _�� f-•✓1j _ _.._ CONTRACTOR: <br /> t <br /> FOR- DEPARTMENT UgE ONLY <br /> PHASE I <br /> 4z <br /> APPLICATION ACCEPTED BY; 0-(J`i�1.C. C ~� DATE: l <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE ,"III/FINAL / <br /> INSPECTION BY: DTE INSPECTION BY s [s' DATE ` !� <br /> E H 1426 - `'SAN JOA UIN-LOCAL HEALTH DISTRICT - 1/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER'- PINK-CONTRACTOR <br />