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FO R OFFICE USE: APPLICATION FOR WELL OR FUME' PERMIT PERMIT NO. 7 Z- 9� <br />' (Complete in Triplicate) Date Issued: <br /> ITHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HERTHE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> r 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: O,'8-0 e 2 OWNER'S NAME: CENSUS TRACT; 3'} <br /> / PHONE: �3�9---S/g3o <br /> ADDRESS: -5-6 CITY: <br /> I CONTRACTOR'S NAME: / LICENSEdIS3 '- /5'-es­PHONE: 6 0 <br /> INTENDED USE: INDIVIDUAL .DOMESTI WATER WELL /% PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7/- <br /> INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL, WELL / / OTHER f_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> i <br /> REPAIRS: TYPE OF REPAIRS: <br /> I <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> r <br /> 1 -HEREBY--CERTfiF'Y-THAT I HAVE PREPARED-THIS APPLICATION'AND THAT-THE 'WORK-WILIr'BEYDONE"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 /> SIGNID: �_ CONTRACTOR: E <br /> 1 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: <br /> DATE: <br /> I <br /> ADDITIONAL COMMENTS: - <br /> I <br /> PHASE II PHASE III/FINAL <br /> f / <br /> INSPECTION BY: DATE INSPECTION BY: -r%✓' DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 ]M ` <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR W � <br />