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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7L- J <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> " I <br /> Sao <br /> s . per- 32- <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 REGULATIgNS OF THE SAN'JOAQUIN LOCAL HEALTH DISTRICT�°° <br /> ( 5'e t 4 f- 7`o <br /> .TOB ADDRESS/LOCATION: S' 7-� CENSUS TRACT: <br /> OWNER'S NAME: ' =1f)v PHONE: - <br /> ADDRESS: �,.� h�cf` CITY: <br /> CONTRACTOR'S NAME: LICENSE # lq.A rMONE: 2:7_�' 76 <br /> D <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL :WE <br /> 7 PUBLIC-WATERLL / / TEST WELL /� <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_INDUSTRIAL WATER WELL /7s <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /T/ 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 /> b <br /> N <br /> PLOT PLAN: SHOW ON REVERSE SIDE s <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 JOA Q IN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br />' DATE: ~ 747 <br /> APPLICATION ACCEPTED BX: z <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> �- X12. <br /> � INSPECTION BY: �`-� DATE _ � INSPECTION BY: DATE �3O " <br /> f E H 1426 SAN JOA UIN -LOCAL HEALTH DISTRIC r 1/72IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />