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FAR OFFICE USE: APPLICATION 'POR WELL OR PUMP PERMIT PERMIT NO. 7 ;-'If'47 <br /> (Complete in Triplicate) Date 'Issued: z <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. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCAT N: r��/dJ /�p . CENSUS TRACT: <br /> OWNER'S NAME: .c T PHONE <br /> ADDRESS: <br /> CITY: <br /> CONTRACTORS NAME. AeY .ti f LICENSE ¢ PHONE: 3-- � <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL / PUBLIC WATER WELL /? TEST WELL/-7IRRIGATION/LIVESTOCK/AGRICUL WATER WELL /-7 INDUSTRIAL WATER WELL L7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L-7 OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTXC TN SEWER LINES � PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD S5� CESSPOOL SEEPAGE PIT ✓ OTHER <br /> REPAIRS: TYPE OF REPAIRSs <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT-I 'NAVE 'PPR ft"I" LICATION AND THAT. THE--WORK--WILL BE SONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN J QUIN, AND THE RULFA AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT., <br /> SIGNED: CONTRACTOR: <br /> FOR DSPARTMJNT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: - --' DATE S "2 <br /> ADDITIONAL COMMENTS <br /> PHASE II PHASE 1117F W <br /> INSPECTION BY: DATE INSPECTION BY: U"- DATE '��'7 7- <br /> E H 1426 SAN JOAQUIN LQ a MMLTH-DISTRICT 1172 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - 'YELIAW FROIRTY OWNER - P13M-CONTRACTOR <br />