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�R OFFICE USE: PLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 Z - S <br /> (Complete in Triplicate) Date Issued: <br /> TH S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR *,RE IT TO PERFORM <br /> THE WORK STATED HEREAFTER. THIS APPLICATIO14 IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1861 AND RULES AND REGULATIONS. <br /> JOB ADDRESS/LOCATION: SEAS_F--Acamro R�� T—e m4 n4, T.=Q, CENSUS TRACT: <br /> OWNER'S NAME: C-1 =4„ Taltbe++ PHONE: <br /> ADDRESS: �., Joaquin <br /> CITY: Acamno <br /> 3R <br /> CONTRACTOR'S NAME: S „Q,,,,;,, p,,,,,,, rr,_LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL -7 PUBLIC WATER WELL/ / TEST WELL 77 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL / // OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 150' SEWER LINES PIT PRIVY SEWAGE <br /> DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDON/DESTRUCTION: METHOD TO BE USED: TI <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 W TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF THE <br /> SAN JOAQPN L AL HWTH n <br /> SIGNED. CONTRACTOR: San Joaquin Pump CoinpanY, ?stc• <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY. 2 DATE: 1 . . . <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHAS III/ -tea 7 Z <br /> INSPECTION BY: DATE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br />