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FOR OFFICE USE: AP MICATION FOR WELL OR PUMA' ?ERMIT PERMIT NO. -7 2,-3y <br /> Complete in Triplicate) Date Issued: <br /> IS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I f{ <br /> APPLICATION IS HEREBY MADE 0 THE SAN JOAQUIN LOCAL11HEALTH 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:: �'� 7 S CENSUS TRACT: J ` 7 f <br /> OWNER'S NAME: 1. /FPHONE: <br /> ADDRESS: P Q, ,9 CITY: <br /> CONTRACTOR'S NAME: � / ICENSE �� PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER. WELL /� PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /�/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL Z_1 OTHER <br /> i <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK ko SEWER LINES PIT PRIVY ;I <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: _ �3 7/c Ii ) S T�z w � <br /> 0, <br /> I <br /> a <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I� <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 /> ACCORDANCtwWITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATION OF THE SAN. JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> 4 <br /> PHASE I <br /> FOR DEPARTMENT FTSE ONLY <br /> ---- <br /> AI <br /> APPLICATION ACCEPTED BY: yP <br /> �i DATE: C 2� 22_ <br /> ADDITIONAL COMMENTS: j <br /> PHASE 4-1 PHASE III FINAL <br /> INSPECTION BY: DATE (� l- 7Z�-- yNS'ECTION BY; z DATE FJ`µZS" 7� <br /> E H 1426 SAN JOAQUIN LOCAL-HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPER OWNER - PINK-CONTRACTOR <br />