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FOR OFFICE USE: APPLICATION,FOR-WELL .OR.PUMP PERMIT PERMIT NO. 7 %3 <br /> (Complete�in.,Triplicate) Date Issued: z <br /> IS PERMIT EXPIRES 1 YEAR FROW DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO .THE'SWJOAQUIN LOCAL ,HEAtTH DISTRICT FOR A PERMIT TO .PWORM } <br /> THE WORK STATED HEREONt' THISFAPPLICATION IS MADE IN'COMP'LIANCE 'WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF .THE SAN JOAQUINrLOCAL -HEALT' i DISTRICT. <br /> JOB ADDRESS/LOCATION: �' Q :�.l� ` " � �. r�: <br /> .J CENSUS TRAC-T <br /> ":. ' <br /> OWNER'S NAME: Pk4l L— I PHONE: <br /> ADDRESS: - CITY: S C-19 L_0^4 <br /> 4 CONTRACTOR'S NAME: ' :4 ° '�-- " �--LICENSE # PHONE: <br /> 4 > 73fCE-...e 153zo <br /> INTENDED USE: IND IVIDU L .DO TIC .WATER_WELL/ ,.PUBLIC-WATER WELL / / TEST WELL-/7/ . .- <br /> 4 IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELT / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK V0 SEWER LINES PIT PRIVY /�LtqiV <br /> SEWAGE DISPOSAL FIELD hLdf4E.ES SPOOL7 SEEPAGE PIT 61hEOTHER ­7- <br /> REPAIRS: <br /> `REPAIRS: TYPE OF REPAIRS: Lam'— r-_pt,_)qC-f_= )-r <br /> 57V Bm W'EL_ SF_R L_ • <br /> s <br /> ABANDONMEI+fT/DESTRUCTION: METHOD TO BE USED: <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: �.- nZ ZZZ7;1,1 CONTRACTOR: <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTEi3-iK-, _ DATE: — — 7 <br /> ADDITIONAL COMMENTS: t <br /> i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: - b—DATE [ INSPECTION BY: DATE ' <br /> E H 1426 . `:-SAN--JOAQUIN"LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />