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APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. _7&- <br /> !EOEFFICE USE: 5� <br /> (Complete in Triplicate} <br /> Date Issued: <br /> THIS 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. 2862 AND RULES AND E ULAT NS OF THE SAN JOAQUI CAS HEALTH DISTRICT. <br /> ADDRESS/LOCATION: C-A CENSUS TRACT: <br /> JOB PHONE: 3 �' <br /> OWNER'S NAME: 'TP' KA,_ CITY: 7_rlt <br /> ADDRESS: 'S'• o LIC SE PHONE: '? <br /> CONTRACTOR'S NAME: +�� _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER /WATER PUBLIC <br /> W TERj <br /> � NDUSTRIALEST WATERLWELL// I <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL I I 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: ` u- / -7 �'� � <br /> '3re,r 0,6 <br /> +[ r rrr id <br /> G � <br /> I <br /> I ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> l <br /> h <br /> I <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THATI 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: 1/ <br /> / CONTRACTOR: 'I <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> DATE: <br /> APPLICATION ACCEPTED BY: <br /> uJ d� U� p I� <br /> ADDITIONAL COMMENTS: <br /> PHASE III FINAL <br /> PHASE II <br /> INSPECTION BY: DATE <br /> INSPECTION BY.: DATE 1/72 1M <br /> KH 1426 SAN JOA UIN`LOCAL HEALTH DISTRI <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PI <br /> NK-CONTRACTOR <br />