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� f <br /> FOR OFFICE USE: AP CATION FORS PIMP PERMIT PERMIT N0. 7 Z, <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z- L -7v <br /> APPLICATION IS HEREBY E 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 S JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION:. D <br /> r� (_ems l Gl caCENSUS TRACT: <br /> OWNER'S NAME I PHONE: <br /> ADDRESS: [t <<xs 'e CITY: ^ <br /> CONTRACTOR'S NAME: i . �. , LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DO ES.TIC WATER WELLPUBLIC WATER WELL / / TEST WELL /7 <br /> RICULTUR <br /> IRRIGATION/LIVESTOCK/AGAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL /_/ OTHER J / <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. dC[ 1 (del•,E- �%� �� � ,�!�'.� . �r-.G� <br /> eL <br /> if ve �t�'a�zC_ Joh G�,tiC� �/�l'��r�aj��! i _fi � Cl1C� �i�..f��-f/ (� i ds4� C�/f <br /> ' - <br /> 7'. <br /> 7r h.t- Or ' 129- 1tA 2S 1JL";fA <br /> n <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> �'_�J�v e C> <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 /> I �_ <br /> SIGNED: t `` F .h^ CONTRACTOR; �( " �.� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE: _4Z21 �^- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: 46!' DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />