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FOR OF P ICE USE: APPLICATION FOR WELL OR PDIP PERMIT PERMIT NO. -7Z <br /> (7 �rJ (Complete in Triplicate) Date Issued: <br /> *� THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED #I <br /> APPLICATION IS HEREBY MADE TO THE 'SAN JOAQUIN LOCAL HEALTH Q LT 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: 1EA7d 0 CENSUS TRACT: <br /> OWNER'S NAME: PHONE: _ k <br /> ADDRESS: /077)_ CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL /41 ___�PUBLIC WATER WELL /—/ TEST WELL /% <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUWELL f_1 <br /> WATER WE / <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL /_/ OTHER <br /> i <br /> i <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK _,60/SEWER LINES LQ PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> • � I <br /> v� { <br /> o <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ` <br /> i <br /> t <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> R <br /> , k <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ; <br /> ACCORDANCEW H THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE k <br /> COUNTY OF JOAQUIN, AND THE ES ANDREGULATIONSOF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: J. DATE: ` <br /> ADDITIONAL <br /> ATE:ADDITIONAL COMMENTS: / <br /> PHHAASEE I>I PHASE III FINAL <br /> INSPECTION BYi�, ---DATE 2 z, INSPECTION BY:DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />