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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 Z L L 5 <br /> (Complete in Triplicate) Date Issued: <br /> _ Y <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. 1852 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: #°�] `�, � n, ;„,�� :_. -- ----- CENSUS TRACT: <br /> OWNER'S NAME: t PHONE: <br /> ADDRESS: ' CITY:ka . <br /> CONTRACTOR'S "NAME: ',�S j '3_ �� y�-, .._e (,,f!�r� LICENSE # 15,3 7.3 PHONE: �6 4. 1112;E _ <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /-7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /—INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PR <br /> SEWAGE DISPOS ELD CESSP EEPAGE PIT <br /> E <br /> REPAIRS: TYPE OF REPAIRS:17 <br /> 4 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: } <br /> f (' <br /> 4 - <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 STATEOF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF,THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: �,/ �j �L:- + ' CONTRACTOR <br /> 1 <br /> FOR DEPARTMENT-USE ONLY ' <br /> PHASE I - <br /> 7-7-1— <br /> PHASE <br /> 5 <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION- BY: DATE4— f2 _ <br /> E H 1426 SAN JOAQUIN -LOCALHEALTH'DISTR_ ICT tl 1/72 1M <br />+ DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER-PINK-CONTRACTOR <br />