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FOR OFFICE USE: _ APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7Z_- 16 6 <br /> (Complete 3n Triplicate) Date Issued: 3- z/- -y <br /> � o THIS 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: iCS' G� CENSUS TRACT: <br /> OWNER'S NAME: I v PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: � LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /? _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER,WELL /—/ INDUSTRIAL WATER WELL / f <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD jCESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> 6. <br /> . cNn <br /> ABMONMENT/DESTRUCTION: METHOD TO BE USED: "t <br /> 6 <br /> 'LOT 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: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DAME— Zp <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br />" INSPECTION BY DATE -20INSPECTION BY:��� • DATE .S` ,V-,"7Z <br /> i" H 14' SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />