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FOR OFTICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. _-7 g 5 <br /> (Complete in Triplicate) Date Issued: 3 <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. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: _ a_a3 ,� ,,% . !',� CENSUS TRACT: <br /> OWNER'S NAME: & / 1p/ ; PHONE: <br /> ADDRESS: _ _ O 3 c, // _ .fs1 -:_ CITY: J'fw �... .. <br /> CONTRACTOR'S NAME: Ito LICENSE # z- HONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /& PUBLIC WATER .WELL /—/ TEST WELL /-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL <br /> / <br /> CATftODIC PROTECTION WELL / GEOPHYSICAL WELL /_/ 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 /> r7 C D <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> C <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 RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: Q / <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE:'- <br /> ADDITIONAL <br /> ATE:ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: � - DATE INSPECTION BY: DATE ?rJ <br /> E H 1426 SAN R&gUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />