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i <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7)_ <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/LOCATION: : 2 -4 Qj 4Tf�Frl�SoA� R Lob CENSUS TRACT: <br /> OWNER'S NAME: ►(_ Il r C7 II�U J PHONE: _ L,5 , C> Q� <br /> ADDRESS: CITY: La pi <br /> CONTRACTOR'S NAME: 1jrx) iu LICENSE 66 2 PHONE: g;e`7•-3 6 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELLPUBLIC WATER WELL /—/ TEST WELL /_7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL j/7 <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL L/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK O, SEWER LINESI101 <br /> PIT PRIVY A)d J6 <br /> SEWAGE DISPOSAL FIELDCESSPOOL SEEPAGE PIT ,OTHER <br /> `i <br /> /0 q <br /> RP R TY�E OF REPAIRS: <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 J N, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: ;aa e,au.c� CONTRACTOR: cG lja"N - <br /> ,,FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY: <br /> f � ,-,,r 1 t;? Ea, •r�J� DATE: > <br /> ADDITIONAL COMMENTS: <br /> j <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE o 7 <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />