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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 L— f ' I. <br /> (Complete in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES 1 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 RE U NS OF THE SAN JOAQUIN LOCAL HEALTH DIS STRICT. <br /> JOB ADDRESSJLOCA ON. CENSUS TRACT: <br /> OWNER'S NAME: PHONE: — '1�- <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE �� �3 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL / f <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> a <br /> I <br /> NEW WELL: DISTANCE TO—NEAREST: SEPTIC TANK SEWER�LINES, ...- PIT_ PRIVY — <br /> �"" SEWAGE DISPOSAL FIELD- CESSPOOL SEEPAGE PIT OTHER — --� <br /> i <br /> L <br /> ; ,.. <br /> REPAIRS: TYPE OF REPAIRS: � I <br /> °�) <br /> ABAND70NMENT/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 1 <br /> ACCORDANCE WITH THE PROVISIONS_OF THE LAWS .OF-THE. STATE-OF CALIFORNIA;THE-ORDINANCES OF THE J <br />=COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: to <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: dt DATE: Z' <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />