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FOR OFFICE-USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. '7 z,--v17 <br />' (Complete in Triplicate) 1,�,; Dare Issued: <br /> IS PERMIT EXPIRES I YEAR FROM DATE ,ISSUED <br /> 5' <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/LOC TION: W 3 CENSUS TRACT:' <br /> OWNER'S NAME; ec& + PHONE: L S- v <br /> ADDRESS: _ .23 ' CITY: <br /> CONTRACTOR'SNAME: LICENSE �� 1 ,3 PHONE: _ G yGa <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATEELL _/ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / T, <br /> INDUSTRIAL WATER WELL <br /> Ir CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /_/ OTHER <br /> j NEW WELL: DISTANCE Tfl T: SEPTIC EWER LINES T PRIVY <br /> SEWAGE DISPOSAL FIEL CESSPOOL SEEPAG -PIT OTHER <br />' REPAIRS: TYPE OF REPAIRS: Fre�F_ <br /> 1 � � <br /> i , <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r <br /> t <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT.THE WORK LL 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 OCAL HEALTH DISTRICT. Ad <br /> i <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ��� t DATE: . <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: LO DATE 61/A -7 Z-- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR/ <br />