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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. _72- Lb 7 <br /> (Complete in Triplicate) Date Issued: 7a <br /> E < 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: � s �, CENSUS TRACT: <br /> OWNER'S NAME: '�� ,,r�°c4 T !;`, _ PHONE: <br /> ADDRESS: /i'G'_� „�:- �a - CITY: <br /> CONTRACTOR'S NAME: -- CCJ LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELXLWATER <br /> PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTU WELL /—/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 1_C") SEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " CESSPOOL SEEPAGE PIT M%jm�OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r <br /> S <br /> r <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 BYE----~� �%'z . . '' -�, DATE: - <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: J � r DATE_'3 7�� INSPECTION BY: / �� DATE 7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />