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FOR OFFI E USE: APPLICATION FOR WELL .OR PUMP PERMIT PERMIT NO. 7 Z�Z <br /> (Complete in Triplicate) Date Issued: Z- '1- 7 L <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: 20, p CENSUS TRACT: <br /> OWNER'S NAME: _ &-;P-D _J' A eg PHONE: <br /> ADDRESS: al 0 A5 C/S - CITY: <br /> CONTRACTORS NAME: C i-0.w r j4 .� . LICENSE f ` `7odS PHONE: <br /> U v " <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL /?: PUBLIC WATER WELL /-/ TEST WELL /7 ___ . <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL 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: vel 5 u�. o tJ�.�U e <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 HEALTH DISTRICT. <br /> a <br /> SIGNED: n o CONTRACTOR: <br /> XYk <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: Z <br /> ADDITIONAL COMMENTS: <br /> - - e <br /> i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY:�J GJ DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT,,,/ 1/7 ]M <br /> DISTRIBUTION. WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - P -CONTRACTOR <br />