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FOR OFFICE USE: APPLICATION FOR WELL OR'--PUMP PERMIT PERMIT N0. 72-- 5, 7_ 0 <br /> (Complete in Triplicate) Date Issued: 5 - 7 L <br /> THIS ERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT Tfl PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE j <br /> NO. 1862 AND RULES AND REGULATIONS OF E SAN JOAQUIN LOCAL HEALTH DISTRICT. # <br /> i5 <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE 4P-$- PHONE: <br /> �L } <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL /Yy PUBLIC WATER WELL / / TEST WELL /7 {€ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER! WELL <br /> CATHODIC PROTECTION WELL f_1 GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> v t <br /> ABANDONMENT/DESTRUCTION: 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 SANja UIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQU1>vjOCAL HEALTH DISTRICT. <br /> SIGNED: &A!� <br /> CONTRACTOR: VvW <br /> Ary <br /> c FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: P <br /> PHASE II P SE I I FINAL <br /> INSPECTION BY: DATE INSPECTION BY:� / DATE 7v _ <br /> 7 <br /> r E H 3426 SAN JOA UIN LOCAL HEALTH DISTRI 1/ i2 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER ( INK ONTRACTOR <br />