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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -7 Z Z`f ,F <br /> (Complete in Triplicate) Date Issued: cF-fi0--12-- <br /> THIS <br /> }-7yTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> D V—cX20—1,3 <br /> APPLICATION IS HEREBY MADS 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 ANDFtULES AND, ULATIONS OF THE SAN `JOAQUIN LOCAL HEALTH DISTRICT. <br /> IN JAL�0?� ��G°T � P�.��E- <br /> JOB ADDRESS/LOCATION: �1J" e eS��¢�cr�' CENSUS TRACT: <br /> OWNER'S NAME: o — A. PHONE: ,1" 3 =3e 9 <br /> e '4,ADDRESS: / � <br /> CONTRACTOR'S NAME:. ,,. `�. LICENSE # f r PHONE: 7.L <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL 1X7 PUBLIC WATER WELL / / 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 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: u.Gl <br /> A 46 <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 4 <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 JOAQUIN, AND HE RULES ANIS GULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY: rU �-� DATE: l� 7Z-. <br /> ADDITIONAL. COMMENTS: <br /> i <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -• PINK-CONTRACTOR <br />