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y ae c <br /> w <br /> FOR OFFXQE USE: APPLICA ION FOR WELL OR PUMP PERMIT P I NO. - 7- <br /> it, 2 SW (Complete in Triplicate) Date Issued:-'"obnt <br /> C" LiS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z y Z-- <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/LOCATI4- CENSUS TRACT: <br /> OWNER'S NAME: PHONE: g72 <br /> - , <br /> ADDRESS: CITY: �! <br /> CONTRACTORS NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL PUBLIC WATER WELL / ,/ TEST WELL /-T <br /> :. /LIVESTOCK/ U z - <br /> INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL f7 OTHER /7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PR ! LY <br /> 5 AG DISPOSAL KELD- _ <br /> E �i ._. . .OTHER <br /> r <br /> REPAIRS: <br /> TYPE OF REPAIRS <br /> 1 44 <br /> ABANDONMENT/DESTRUCTION!/METHOD TO BE <br /> r- <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY-CERTIFY-11W-1- HAVE 46E IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN OAQUIN, THE RULES AND REGULAT%ON$ OF In SAN JOAQUIN LOCAL HEI TH DISTRICT. <br /> SIGNED: - L t CCTDR <br /> FOR DEPARTMENT USE ONLY; <br /> PHASE I <br /> APPLICATION ACCEPTED BY h DATE <br /> ADDITIONALCOMMENTS: <br /> PHASE .II PHASE III FINAL <br /> INSPECTION BY: <br /> DATE INSPECTION BY. DATE <br /> E 8 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT YELLOW-PROPERTY OWNER - PINR-CONTRACTOR <br />