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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. '7 Z. 2- <br /> c. J <br /> - ((Complete in'Triplicate) Date Issued: <br /> T IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLIC 4N�ISIHEREBY 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 RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 1 <br /> JOB ADDRESS/LOCATION: L`t� �' CENSUS TRACT: <br /> OWNER'S NAME: = L PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: i ; LICENSE r + " PHONE: if 1. mwj <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 ]/Z/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANKLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD s CESSPOOLS PAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: � Lv E l� <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 STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND TH RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: <br /> DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE 6-"2,y- 2- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />