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FOR OFFICE USE: � �APPLICArAN FOR <br /> WELL OR PERMIT NO. 7L -/ 7 <br /> (Complete in Triplicate) Date Issued: 3 � <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 FLULES AND, AEWLATIO S0 T E OAQUIN OCAL HEALT DISTRICT. <br /> ✓1� j 'f v� G <br /> 4OOBADDRESS/LOCATION: CENSUS TRACT: <br /> WNER'S NAME: "PHONE: <br /> ADDRESS: t2 <br /> CITY: <br /> CONTRACTOR'S AME: KENS ! T2Zffd�.6 PHONE: <br /> INTENDED USE: INDIVIDUALDOM STIC WATER WELL PUBLIC WATER WELL / / TEST WELL / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL ,( J INDUSTRIAL WATER WELL /- <br /> CATHODIC PROTECTION WELL GEOPHYSICAL WELL �/ OTHER <br /> NEW WELL: I54 <br /> ST CE TO NEAREST; EPT� TANK/Q'i ) SEWER LINES e � PI � /y LJ <br /> SEWAGE DISPOSAL FIELD; CESSPO6L7SErEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ARM NT/DESTRUCTION: METHOD TO BE USED: Q <br /> J� <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: CONTRACTOR: <br /> v Z7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: Z -7 Z, <br /> ADDITIONAL COMMENTS; <br /> PHA <br /> o f i� f Y I I/ INAL <br /> INSPECTION � �u Pum <br /> BY: / '�3ATE y / J z� IE5PECT N BY: DATE <br /> E H 142b SAN JOAQUIN, LOCAL HEALTH DISTRICT 1/72 <br /> DISTRIBUTION- ITE-HEALTH DISTRICT- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />