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FOk OFFICE' USE i` ,,,,. APPLICATI FOR WELL OR PUMA' PERMIT PERMIT NO- 7m - 1 J <br /> (Complete in Triplicate) Date Issued: <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 OFpTHE <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCAT ON: I -E`�9 + J u�,lL ,` CENSUS TRACT: <br /> OWNER'S NAME: L� c PHONE: <br /> ADDRESS: V? Ch. �'A T" ." _ _ CITY: <br /> CONTRACTOR'S NAME: �Jk F c—S. LICENSE 2oA PHONE: . is <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /% TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELLINDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL j f GEOPHYSICAL WE LL% OTHER / / <br /> 04 <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 /> 0 <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 /> ACC RDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COU TY OF JOAQUIN, AND-TIIE RULES AND EGU TIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED• / E <br /> ` CONTRACTOR: aA. At <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: J 2_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE _� 3r-2 <br /> E H 1426 SAN-JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />