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FOR OFFICE USE: APPLI ATION FOR WELL OR PUMP PERMIT PERMIT NO. ' 7 L-13 2- <br /> -- <br /> (Complete in Triplicate) Date Issued: 7a <br /> IS PERMIT EXPIRES- 1- YEAR FROM DATE ISSUED <br /> i <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.46%X1 <br /> Ea ern, CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: P 0 CITY: <br /> CONTRACTOR'S NAME-- <br /> ( ' LICENSE # I6,� 3�3 PHONE <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / I PUBLIC WATER WELL / / TEST WELL F7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /X/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTIONWELL / -/ "GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTAN TO NEA SEPTIC SEWER L • �S PIT <br /> I 7�1 <br /> SEWAGE DI OSAL FIEL CESSPOOL ��PAGE PITC THER <br /> REPAIRS: TYPE OF REPAIRS: 74 QaJ U <br /> ' 4 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> F PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILVBE 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. N <br /> SIGNED: <br /> CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: _2— <br /> ADDITIONAL <br /> -ADDITIONAL COMMENTS: <br /> i <br /> PHASE II P II FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE .� <br /> E H 1426 SAN' J0A UIN LOCAL HEALTH DISTR1/ 2 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -CONTRACTOR <br />