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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT V PERMIT N0. 7 L-17 <br /> (Complete in Triplicate) Date Issued: 3 -z 2- 7KL <br /> I'S 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 /> THE WORK STATED HEREON. THIS ,APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE AN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: L ✓ CENSUS TRACT: cS 8 <br /> OWNER'S NAME: PHONE: <br /> CITY: <br /> ADDRESS: o -LICENSE 11 PHONE: <br /> CONTRACTOR'S NAME: �� <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 / / OTHER <br /> 'NEW`WELL:"`DISTANCE\TO NEAREST:' SE IC TANK 4 SEWED PI VY _ <br /> SEWAGE DISPOSAL FIELD SEEPAGE PIT OTHER <br /> REPAIRRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 9 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> 1 <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: /9 <br /> 1&. <br /> FOR DEPARTMENT USE ONLY <br /> I ) <br /> PHASE I <br /> APPLICATION ACCEPTED BY: '-c4 SDATE: a� <br /> ADDITIONAL COMMENTS: + <br /> I <br /> PHASE II ! PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: / DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> j DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />