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FOR OFFICE USE: APPLICATION FOR WELL OR PUMA' PERMIT PERMIT NO. 7 2-- Z:1( L <br /> (Complete' in ,Triplicate) Date Issued-: .��� <br /> HIS PERMIT EXPIRES I YEAR FROM 'DATE ISSUED <br /> • E <br /> APPLICATION IS HEREBY MADE TO TH 'SAN �JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE SIN COMPLIANCE WITH COUNTY ORDINANCE <br /> N0. 1862 AND RULES AND REGULATIONS OF <br /> . THE SAN-'JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: CENSUS .. <br /> TRACT:_ <br /> OWNER'S NAME: C, Lz AjPHONE: <br /> ADDRESS: ' ` <br /> CITY <br /> CONTRACTOR'S NAME: LICENSE lE PHONE: <br /> . <br />+ INTENDED USE: INDIVID[1AL,.DOMESTIC WATER WELL /!Pf PUBLIC WATER WELL /�/ TEST WELL <br /> IRRIGATION/LIV-ESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC 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: D12. Q ` , <br /> Ow <br /> ABANDONMENT/DESTRUCTION.: METHOD TO BE USED: n <br /> � d <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 SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> i <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> d <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: ..� ` DATE <br /> E H 1426 SAN_JOAQUIN LOCAL HEALTH DISTRICT 1./72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR. <br />