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FOR OFFICE USE: V APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7L--lo <br /> (Complete in,.Triplicate) Date Issued: -7 ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE To 'THE SAN-JOAQUIN LOCAL"HEALTH DISTRICT FOR k 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 /> .TOB ADDRESS/LOCATION: CENSUS TRACT: ' S- L5 . <br /> OWNERS NAME: ,�„� PHONE: g��5 � t3, c� - -- 1, <br /> ADDRESS: L r CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL-DOMESTIC-WATER WELL / y •PUBLIC. WATER WELL / / - TEST WELL. /—/ _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 2n� SEWER LINES �7j SPIT PRIVY F <br /> SEWAGE DISP SAL FIEL CESSPOOL SEEPAGE PIT OTHER ' <br /> 100, <br /> REPAIRS: TYPE OF REPAIRS: -- - - <br /> r ' <br /> e <br /> ABANDONMENT/DESTRUCTION: METHOD' TO BE-USEDo of <br /> ol <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY-THi4T-1-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 JOAQU , AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> i <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: r �_ - ____ - _-- DATE: <br /> ADDITIONAL COMMENTS: <br /> A' <br /> PHASE II . .. PHASE III/FINAL �.. <br /> 3_ <br /> INSPECTION BY:/ (� DATE J-d _7 - INSPECTION BY: DATE Z 2 <br /> E H 1426 -"- SAN-jOA.QUIN-LOCAL HEALTH_ DIST_RIC_T 1/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />