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XOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 <br /> o (Complete in Triplicate) Date Issued: a. -fir -7 -z- ; <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED 7 <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: "° } rs- ren CENSUS TRACT: <br /> OWNER'S .NAME: PHONE: <br /> ADDRESS " fd� � C ITY <br /> CONTRACTOR'S NAME: As LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL J PUBLIC WATER WELL / / TEST WELL /7 .� <br /> IRRIGATION/LIVESTOCK/AGRICUL WATER WELL /7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> ; <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT RIV <br /> PY�I�Y� r <br /> SEWAGE DISPOSAL FIELD /`CESSPOOL SEEPAGE PIT/62i OTHER <br /> REPAIRS: TYPE OF REPAIRS: i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BEATSED:' h fl <br /> t - <br /> r' <br /> PLOT PLAN: SHOW ON �REVERSE SIDE , <br /> _t I € <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THEPROVISIONS 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE v <br /> ADDITIONAL COMMENTS:'4__ - <br /> j app xJGeLQ G�i4Zc� c'GG�t�x� dI a4 n x;-c �, <br /> 'PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 r SAN' JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> 4 <br />