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FOR OFFICE USE: APPLICA ION FOR WELL OR PUMP PERMIT PERMIT. NO. 7 2- 1 <br /> (Complete in Triplicate) Date Issued: .-3 -7 <br /> HIS 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 /> JOB ADDRESS/LOCATION: - _ ,1 CENSUS TRACT: S <br /> OWNER'S NAME: �Ir���1J �/��.t�. .tI7-�.[/ PHONE: 9-- <br /> ADDRESS: CITY: <br /> LICENSE #, <br /> CONTRACTOR'S NAME: O?�PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC.WATER WELL. J / PUBLIC WAT R WELL•/ / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICUL <br /> MAP, WELL _ <br /> / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL J J GEOPHYSICAL / / OTHER , /_7 <br /> Y6-(219-it S <br /> NEW WELL: DISTANCE TO NEARES SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD v CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: 'TYPE OF REPAIRS-.--- <br /> ABANDONMENT/DESTRUCTION: <br /> EPAIRS:ABANDONMENT/DESTRUCTION: METHOD TO BE .L1S6': <br />-PLOT-PIAN: SHOW'ONTREVERSE'�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 LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JO Q IN, AND THE U S ' REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. ; <br /> SIGNED: , CONTRACTOR: <br /> PWi <br /> FOR DEPART 'NT USE ONLY <br /> PHASE I <br /> x <br /> APPLICATION ACCEPTED BY: _ ----_ DATE: J��' �• <br /> ADDITIONAL COMMENTS. <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: "f DATE INSPECTION BY: //� DATE 3 <br />-E H 1426 .SAN JOAQUIN LOCAL HEALTH DISTRICT` �'�` �""""" - 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />