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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 7 Z- 16 3 <br /> (Complete in Triplicate) Date Issued: '.I_-,, Z-7 Z, <br /> TH PERMIT EXPIRES I 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: J V"42CENSUS TRACT: <br /> -OWNER'S NAME: PHONE: `l,,, <br /> ADDRESS: ""' CITY <br /> CONTRACTOR r S NAME: LICENSE # � PHONE: 6_13 <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER--WELL 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 -'.'D" SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> Vi <br /> REPAIRS: TYPE OF REPAIRS: <br /> L, <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r <br /> .f. V . <br /> PLOT PLAN: SHOW ON REVERSE SIDE M ;� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE D.ONEiIN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF-THE- STATE-OF CALIFORNIA; THE ORDINANCES ,OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RUL AND REGULATIONS OF THE SAN JOAQUIN`LOCAL"HEALTTH DISTRICT, <br /> i SIGNED: CONTRACTOR: <br />{ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I "S <br /> APPLICATION ACCEPTED BY: _ Gd- C� _ DATE: `0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> t INSPECTION BY: �y DATE _� � r ~ INSPECTION BY: ��.._ Qy <br /> DATE 3��1-� <br /> E H' 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />