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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 7,- a W <br /> (Complete in Triplicate) Date Issued: s. <br /> 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. 1$62 AND RULES AND aGULATIONS OF THE SAN JOAQUIN LOCAL, HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT: 7 <br /> OWNER'S NAME- PHONE: <br /> ADDRESS: d CITY: <br /> CONTRACTOR'S NAME: V_Gd- LICENSE # /,4- 6 � - <br /> PHONE: f <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL . PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL <br /> / <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT 4.00 OTHER <br /> REPAIRS: TYPE OF REPAIRS: <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 LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: D - <br /> ADDITIONAL COMMENTS: <br /> PRASE II PHASE III FINAL <br /> INSPECTION BY: 2� DATE /a ',1-6 7� INSPECTION BY: DATE Is-• <br /> E H 1426 SAN JOAQT LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />