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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT .�h PERMIT NO. 7 2 _�4 �o <br /> (Complete in Triplicate) Date Issued: 3-�6 <br /> 7L <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISS D <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. 1 <br /> JOB ADDRESS/LOCATION: / d�.� f�L�J�'/� CENS S TRACT: � � <br /> OWNER'S NAME: PHONE <br /> ADDRESS: _ ,3 j =, rr CITY: d, <br /> CONTRACTOR'S NAME: LICENSE # LLIPHONE: � � 5r <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER JELL /PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL—/—// OTHER <br /> NEW WELL: DISTANCE TO NESEPTIC TANK SEWER LINES-------TIT PR <br /> SEWAGE DISPOSAL FIEL SEE <br /> CESSPOOL PA PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: _, - (4, <br /> i <br /> Vi <br /> ABANDONMENT/DESTRUCTION: <br /> 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: r,in, h �� [' t t is za CONTRACTOR: 41 � <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: C DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE I I FINAL <br /> INSPECTION BY: DATEr <br /> INSPECTION BY: DATE 3 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRI 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />