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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7Z <br /> (Complete in Triplicate) • Date Issued: <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> z-- <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 /> 1862 AND RULES ANP <br /> GUS=I0 S 0E S JOAQLi1,NL0 �iEALTH D�I5TRICT�. <br /> JOB ADDRESS/LO ATION T/L�r. CENSUS TRACT: <br /> OWNER'S NAME: PHONE: '? <br /> ADDRESS: CITY: L.oDl <br /> CONTRACTOR'S NAME: t' pLC LICENSE 4� .1PHONE: -3 3 L _3 <br /> INTENDED USE:. INDIVIDUAL DOM], WATER WELL / PUBLIC WATER WELL / / TEST WELL _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / ( INDUSTRIAL WATER WELL / J <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK ikkER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> REPAIRS, TYPE OF REPAIRS: „��/' "J I7�� g <br /> E <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> F <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: CONTRACTOR: jZZ-0T ' <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �' ! �� • , DATE: <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATEINSPECTION BY: SATE <br /> # <br /> E' H 1426 - SAN -JOAQUIN LOCAL HEALTH DISTRICT fid-- 1/72 1M' <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />