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r - <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 Z- Z'5 7 <br /> 4a 01 (Complete in Triplicate) Date Issued: ,� -2 7 y <br /> IS 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: AZZ/2- ' jV �,ENSUS TRACT: ' I <br /> OWNER S NAME: PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL f_1 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDli-ST-RIAL WATER WELL % <br /> CATHODIC PROTECTION WELL El GEOPHYSICAL WELL L/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> a <br /> 00 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: .17 <br /> eo <br /> S <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 ACCEPT DATE: - `L <br /> ADDITIONAL COMMENTS: ~� 7 <br /> PHASE II <br /> PHASE <br /> '' III FINAL <br /> INSPECTION BY: DATE INSPECTION BY:T 9 01 DATE -L-11f _ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />