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FOR OFFICE USE: %ZAPPLICATION FOR WELL ORIrPUMP PERMIT PERMIT NO. Z .z Z 7 <br /> (Complete in Triplicate) -r -, t- � Date Issued: �?. <br /> MIT EXPIRES 1 YEAR FROA1 '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/LOCA ION: CENSUS TRACT: <br /> OWNER'S NAME: PHONE: �JJ 8 . _5 <br /> ADDRESS: 13H , <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 <br /> 1 CATHODIC PROTECTION WELL j I GEOPHYSICAL WELL / / OTHER I / <br /> NEW WELL: DISTANCE'"TO x.N&MST: SEPTIC T -,SEWER LIN!,,_ PIT PRIVY <br /> SEWAGE DISPOSAL . CESSPOOL AGE PIT OT <br /> REPAIRS: TYPE OF REPAIRS: <br /> /i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ,- <br /> � N <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONEeIN -' <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 THESAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> n,. ,.. �.f _— -�--- <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: -- <br /> DATE: 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: �� DATE 6 1 <br /> E H 1426 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />