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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 7Z-1 7 <br /> (Complete in Triplicate) Date Issued: _3 -z z- 7 <br /> 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 SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> Jo / ��� ggqqqq <br /> JOB ADDRESS/LOCATION: Jnx 3 3 te� / CENSUS TRACT: cS `� <br /> PHONE: <br /> OWNER'S NAME: / <br /> ADDRESS: Al CITY: <br /> CONTRACTOR'S NAME LICENSE L�.�7_4 PHONE: ii /_G..96J5: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER'WELL / / PUBLIC WATER WELL /TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAI. WATER WELL / / INDUSTRIAL WATER WELL I /—/ <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL %/ OTHER / <br /> I <br /> T <br /> 'NEW`WELL:"DISTANCE TO NEAREST:l.SE IC TANK 4 SEWEit INE3� PI <br /> SEWAGE DIS FIELD L SEEPAGE PIT OTHER j <br /> REPAIRS, TYPE OF REPAIRS: 1ILL , PiSL <br /> � <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> rC <. <br /> t114.1 . <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> -HEREBY-CERTIFY`THAT-I• HAVE PREPARED-THIS APPLICATION AND-*T THS WORK WILL IN CES <br /> IN <br /> I <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: nT�14, ���IJ CONTRACTOR: <br /> .17 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> V APPLICATION ACCEPTED BY: X e moi'' DATE: <br /> ADDITIONAL COMMENTS: <br /> IJ PHASE II <br /> PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: % DATE -2�'7 <br /> E H 1426 SAN JOAQUYN LOCAL HEALTH DISTRICT 1/72 7M <br /> i DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />