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FOR OFFICE USE: A KATION FOR WELL OR PUMP PERMI PERMIT N0. 71 T3 7 <br /> `J (Complete in Triplicate) — Date Issued: - 7 Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �Sr7Y c, <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 /> // ' <br /> JOB ADDRESS/LOCATION: 7tC. /' .A l"A 0 CENSUS TRACT: P <br /> OWNER'S NAME: ;" �✓J C, PHONE: <br /> ADDRESS: GS CITY: <br /> CONTRACTOR'S NAME: j- ELZ//,{Q(aLICENSE # 71,60ZPHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK C SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PITY_ OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> f <br /> Q1 <br /> ABANDONMENT/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 <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 OCAL HEALTH DISTRIC . <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: &/ DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: \tk"o—\'"�°� DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRIC51/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> Gid <br />