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FOR OFFJCE USE: )(,� APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' 7Z- "%(Complete in Triplicate) Date Issued• -7PERMIT-EX•PIRES-1 tEAA 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 /> f�(.�`Yj7'l�� acs•+-i.."`t7r ' - .. <br /> JOB ADDRESS/LO TIO - ENSUS TRACT: <br /> OWNER'S NAME: PHONE: (a(Q— l <br /> ADDRESS: e CITY: I <br /> CONTRACTOR'S NAME: . �LICENSE # 2 ? PHONE: (o <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL �,,,PUBLIC WATER WELL /�/ TEST WELL. /_7 <br /> IRRIGATION/LIV-ESTOCK/AGRICi3LTURIiL EWfgR WELL /% INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYST-CAL WELL / / OTHER <br /> --�ww.wfby� �rr�--�-�.+.:'+'..r+r.-^r�C-•'rw3# -tr-.Y �.�+.n;:+ne'- i <br /> NEW WELL: DISTANQJE TO N ST: SE IC TANK !SE LINES PIT RIVY <br /> SEWAGE D OSAL F D SPOO�AGE HER i <br /> REPAIRS: TYPE OF REAIRS) e r <br /> Y 8 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: � <br /> e `, <br /> PLOT PLAN: SHOW ON REVERSE SIDE ��•.\ <br /> I HEREBY HAVE PRE ED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORD CE WITH THE PROV IONS 0 T S��OF THE _STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY F SAN JOA UIN, TH �`R REGU �i-14E SAN JOA Q N LOCAL HEAL DISTRICT. <br /> AT k <br /> SIGNED: ;; /(� CONTRACTOR: <br /> FOR DEPARTMENT' USE ONLY <br /> PHASE I �i <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: I <br /> PHASE II P FINAL <br /> i <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 �I SAN JOA UIN LOCAL HEALTH DISTRI <br /> - 1/7'2 1M <br /> DISTRIBUTION; WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -C NTRACTOR }`{ <br /> f3 <br />