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u <br /> OWL <br /> r <br /> ' F USE: ArrLICATION FOR WELL OR PURI: PFRM11 PERNIT NO. 7.) ?1 <br /> (C,onp fete in Triplicate) Date Issued: A=,F• 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DTSTRTCT FOR A PERMIT TO PERFORM <br /> 1 THE WORK STATED HEREON, THIS APPLICATION IS MADE IN COt,''IiANCE WITH COUNTY ORDINANCE. <br /> I1 NO. 1862 AND RULES AND RF,CITTATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LO(;ATION: -��=- )�' <br /> & CENSUS TRACT: <br /> OWNER'S NAME: ��/��y L LLE L' PHONE: <br /> ADDRESS: / N —P-J/,)/T/NG CITY: _ <br /> CONTRACTOR'S—NA.MF�: LL� f )i r�(�LICENSE U PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATEC WELL A7 PUBLIC WATER WELL L-7 TEST WELL 1-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL :TATER WFF.L /—TIN'DUSTRIAL WATER WELL /� <br /> ,'ATHODIC PROTECTION WELL /_/ CEOI'11"ICAL WELL L% OTHER / <br /> NEW WELL: DISTANCE Tn NEAREST: SEPTIC TANK 3-C SEWER LINES PIT PRIVY _ <br /> SEWAGE DTSPOSAL FIELD CESSPOOL SEEPAGd PIT OTHER <br /> REPI.IRS: TYPE. OF REPAIRS: <br /> ARANDONHF.NToo/DF.STRUCT^vION:(� METHOD(� TO BE USED: �c <br /> 1Ltibt.Vim!SAID,O.Lc�Ya?L �Tt X , C� �� ��Y�"�sTT _ }~ <br /> PLOT PLAN: SIIO., IN REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE Itl <br /> ACCORDANCE. WITH THE PROVISIONS OF THE LAWS OF THE STATE. OF CALIFORNIA , THE ORDINANCES OF TU <br /> COUNTY OF SA': AND THE RULES AND RCGIILATTONS OF THE SAN JOAQUIN_1�CAT. HEEALLTHH,ODDIISTRI <br /> SIGNED: CONTRACTOR: k 1t=��- -�--_^ <br /> FOR DEPARTMENT USE ONLY <br /> PPASE I <br /> APP:.ICATIr: f.':".�"I'T f') liY: �j��_ DATE: _�/ ✓/ <br /> ADDITIONAL. r ,_'.^•'..':T': _� _ <br />