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FOR OFFICE USE: f APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -7 Z- S <br /> (Complete in Triplicate) Date Issued: Z - /7- -7 <br /> i <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 BLOC HEALTH DISTRICT. <br /> A0 GC/. ,� tt/,F�/Q � Ivy�.t•�c, <br /> JOB ADDRESS/LOCATION: / ell �CENSTRACT <br /> OWNER'S NAME: /r.',Pf,p.,.!, rte_ PHONE: 6 _ q,3411 <br /> 41 <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE # 1(,,9j43 PHONE: i� 6 4 - <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /—/ PUBLIC WATER WELL /—/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /X/ INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL L/ OTHER /_7 <br /> NEW WELL: DISTANCE T EAREST: SEPTIC TAiW, SEWER ` l ES-,_ PATZRIVY <br /> SEWAGE DISPO IELD EsspodlMnPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: ��,�.� fi'� �;, <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 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: 1 DATE: _VI"17 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> j <br /> INSPECTION BY: DATE INSPECTION BY [ DATE —3 • /S` <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRI T 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />