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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT /J�,�ln' RMIT NO. -7 ? • Z 3y <br /> (Complete in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE IS D <br /> 4 <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. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �� y C��Q%e./c��' CENSUS TRACT: <br /> OWNER'S NAME: ,d+,.• _ ._ _ � PHONE: <br /> ADDRESS: _/ *17 C r, ��, ,tf./ CITY: tri; <br /> CONTRACTOR'S NAME: t „�, LICENSE # 4 2 3 73. PHONE: *4 4 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL j' PUBLIC WATER WELL /—/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE TON EST: SEPTIC TANKSEWER LINk&— � <br /> — IT PRAM_,_ <br /> SEWAGE DISPOSAL FIS _CESSPOOL IT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTIO METHOD TO BE USED: <br /> q� <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 /> SIGNED: _ ' CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: llb <br /> lll> <br /> ADDITIONAL COMMENTS: <br /> PHASE II MS—II INAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DIS 1/72 1M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER P — CTOR <br />