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FOR OFFICE USE: �} APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. `7 Z- <br /> (Complete in Triplicate) Date Issued: Z-i 5.- _7 l/ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM r <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: ' -5 t, CENSUS TRACT: SSI <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE # 42,3 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> / <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DIST NEAREST: C TANK S -LINES PRIVY <br /> SEWAGE DISPOS 'LD CES SEEPAGE PIT .----,OTHER <br /> REPAIRS: TYPE OF REPAIRS: xz <br /> A <br /> �i <br /> ABANDONMENT/DESTRUC ON: METHOD TO BE USED: <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: r,. (��{�a1 CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: 'Q2 /16 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE <br /> E H 1426 SAN' JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />