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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -72-- '71 <br /> (Complete in Triplicate) Date Issued: 3_ -7� <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/LOCATION: T- J16 >Z/ _ CENSUS TRACT: <br /> OWNER'S NAME: ` PHONE: / 1 7 <br /> ADDRESS: s— * CITY: <br /> CONTRACTOR'S NAME: LICENSE # i PHONE: 36 eoS� 7/ <br /> INTENDED USE: INDIVIDUAL STIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL L-7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL 1,�;T�INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL ,C/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REnA-TRgy IqW QE R EATRS y l _ <br /> f, <br /> c� <br /> I <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JO IN, AND THE RULES AND' EGU TIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: -CONTRACTOR: <br /> FOR D,9PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: !. -' it f. f/ DATE• <br /> ADDITIONAL COMMENTS: <br /> PHASE II PMHA III FINAL <br /> INSPECTION BY: DATE INSPECTION BY. (J DATE � Z <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />