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FOR OFFICE USE: aZICATION FO WELL �R PUMP PERMIT PERMIT NO. 7 Z Z 6 Z <br /> � 1 <br /> (Complete in Triplicate) Date Issued: - f -7 ?-- <br /> THIS PERMIT EXPIRES I 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 REGULATIONS OF THE SAN JOAQUIN LOC HEALTH .DISTRICT. <br /> 70B ADDRESS/LOCATIOI3 r Y r �' "` CENSUS`TRACT: <br /> TOWNER'S NAME: HONE: <br /> ADDRESS: y CITY: k <br /> CONTRACTOR'S NAME: Atr) F,' L ENSE #. „f` PHONE: <br /> INTENDED USE: IND' VIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL/_/ GEOPHYSICAL WELL ;/_/ OTHER f_1 <br /> VEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS* TYPE OF REPAIRS. <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> 4 <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: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: d DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE I INAL <br /> INSPECTION BY:RITE—HEALTH <br /> DATE �/ — Z � INSPECTION B TE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DIST 1/72 1M <br /> DISTRIBUTION DISTRICT - YELLOW-PROPERTY OWNER - NTRACTOR <br />