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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -7 Z- '5 <br /> (Complete in Triplicate) Date Issued: <br /> IS <br /> PERMIT EXPIRES 1 YEAR FRAM 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. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALT DISTRICT. <br /> l 21 0 l'U ' 14F1�'jx� TS <br /> JOB ADDRESS/LOCATION: j z � L ' 3i�`�1 ENSUS TRA / <br /> OWNER'S NAME: x PHONE: L,C� , . p�•f,�� <br /> ADDRESS: CITY: '�ql <br /> CONTRACTOR'S NAME: 2 d LICENSE �E IX,42 01Z273 PHONE: �24 6-f(a$_ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /. /_INDUHSTRIAL WATER WELL <br /> / <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DIST TO NEAREST: PTIC TANK SEWER LINE PIT VY <br /> SEWAGE DI SAL FIELD SSPOOL SEEP PIT HER <br /> e <br /> REPAIRS: TYPE OF REPAIRS: <br /> � O <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ' <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 STATEkOF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: 10CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: r DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />