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4 AIL_ <br /> FOR OFFICE U E: APPLICATION FOR WELL OR PUMP PERMIT,,,, PERMIT NO. 7 <br /> (Complete in Triplicate) Date Issued: Z-L 5.7 Z <br /> IS PERMIT EXPIRES l YEAR TROM DATE ISSUED <br /> I APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMITJO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1$62 AND RULES AND REGULATIONS _' THE SAN JOYUIN LOCATHEALTH DISTRICT; � <br /> JOB ADDRESS/LOCATION: f CENSUS TRACT: A <br /> 4 OWNER'S NAME: PHONE: 7 _ <br /> ADDRESS: / ,-�cJ�T CITY: :3 o <br /> CONTRACTOR'S NAME: ctT�3 1/J�-1'� 5, LICENSE #/ <br /> � PHONE: AC6 6 <br /> INTENDED USE: INDIVIDUAL ,DOMESTIC WATER WELL / / PUBLIC WATER WELL /,V-lz TEST WELL <br /> t IRRIGATION/LIVESTOCK/AGRICULTURAI;-WATER WELL / /_INDUSTRIAL WATER WELL <br /> r �ATHODIC 'PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> 41 <br /> NEW WELL: DISTANCE TO NEAREST:L ;SEPTIC WER LINE IT PRIVY <br /> SEWAGE DISPOSAL�FIEL-D- - CES OOL SEEPA E PIT OTHE { <br /> i <br /> \ s t <br /> REPAIRS: TYPE, OF REPAIRS Y ._. 7"9-'1 I`. f /C 3e-d,4 <br /> I <br /> ABAND NMENT/DESTRUCTION: METHOD TO BE`U$ED: <br /> Fn�� . ,!(-\ <br /> � I r i <br /> H <br /> \ 1 <br /> PLOT PLAN: SHOW ON REV1 'SE- SIDE - -- <br /> t <br /> I HEREBY CERTIFY THAT I VE PRE EDT PLICATION AND THAT THE WORK WILL' BE DONE IN <br /> ACCORDANCE WITH THE PROV SIONS-- F THE WS OF'•THE'�STATE OF.,CALIFORNIA, ORDINANCES OF <br /> COUNTY 0 SAN JOAQUIN RU r AND GULA ISE' SAN JOAQUI / OCAL DI CT. <br /> SIGNED: CONTRACTOR: 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: Z t Z- -r- <br /> ADDITIONAL COMMENTS: 1 i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY,:W t "Vo DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />