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FOR�OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 7 2 L �v " <br /> (Complete: in Triplicate) Date Issued: <br /> T IS PERMIT EXPIRES l 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. 7 <br /> JOB ADDRESS/LOCATION: Fr c a C CENSUS TRACT: /?A A <br /> OWNER'S NAME: PHONE: 4!j <br /> ADDRESS: 2 — CITY: g Z& nA G A t 17� <br /> CONTRACTOR'S NAME• LICENSE # PHONE: G 6 u 4 k 1g_ <br /> r <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL DSI PUBLIC WATER WELL / f TEST WELL /� — <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK S/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' S <br /> REPAIRS: TYPE OF REPAIRS: a► <br /> i <br /> � - <br /> ABANDONMENT/DESTRUCTION: 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- TIIE--LAWS-OF-THE-STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN J UIN, &ANTHE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: ,� D THE RULES AND -REGULATIONS OF LSI CONTRACTOR: �L <br /> • .M1 R <br /> 6 <br /> ' FOR DEPARTMENT 'USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II1 PHASE III FINAL <br /> INSPECTION BY: !�: DATE _ _ INSPECTION BY: DATE _ " 7 rte✓ <br /> E H 1426 "' SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />