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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 Z 'F 3 <br /> (Complete in Triplicate) Date Issued: 2--l5 -ry <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM' <br /> FHE WORK S'T'ATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> 0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> �AOB ADDRESS/LVeffnlAN: CENSUS TRACT: <br /> WNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> ONTRACTOR'S NAME: LICENSE PHONE: <br /> _VTENDED USE: INDIVTDUAL .DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULT WATER WELL j_/ INDUSTRIAL WATER WELL <br /> l F11 <br /> CATHODIC PROTECTION WELL / f GEOPHYSICAL WELL /_/ OTHER / / <br /> f <br /> FEW WELL. DISTANCE TO NEAREST: ' <br /> .SEPTIC TANK` 0 f4- SEWER EINES 70 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD !`650—CESSPOOL/SEEPAGE PIT IV0 OTHER /1.°-0`L.e <br /> REPAIRS: TYPE OF REPAIRS: <br /> �, 77 <br /> a <br /> ABANDONMENT/DESTRUCTION: METHOD TO 'BE USED: <br /> i <br /> w , <br /> OT PLAN: SHOW ON REVERSE SIDE <br /> F ' <br /> � HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> SCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> WUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> HAS, I <br /> PLICATION ACCEPTED BY: �,�//d'`�/� _ DATE: <br /> ITIONAL COMMENTS: <br /> L ! PHASE II PHASE- III/FINAL <br /> INSPECTION BY: > _- DATE INSPECTION BY: DATE 1 <br /> I H 1426 SAN JOA UIN LOCAL HEALTH DISTRI 1/72 IM <br /> IH <br /> WHITE--HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />