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FOR OFFICE USE: APPLICATION FOR WELL OR FUMP PERMIT PERMIT NO. 7 2-, J <br /> _ (Complete in Triplicate) Date Issued: 15_ -7 z <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 /> 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. C <br /> JOB ADDRESS/LOCATION: ,�� � 7 <br /> fLlj�al CENSUS TRACT: <br /> OWNER'S NAME: - PHONE: " " 2- 1JV O <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE #g.L.' " PHONE: '� L <br /> INTENDED USE: IND VIDUAL 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: SEPTIC TANK SEWER. LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> n.J <br /> fi <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 LOCAL HEALTH DISTRICT. <br /> SIGNED: C ) CONTRACT--OR: S / / <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: 1 <br /> ADDITIONAL, COMMENTS: A <br /> •1. <br /> PHASE II PHASE II FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE ��- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW--PROPERTY OWNER - 'PINK-CONTRACTOR <br /> i <br /> tic .._. <br />