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F-7) <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -7 L45 G , <br /> (Complete in Triplicate) : Date Issued: z_e1 72 <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED =.r � <br /> APPLICATION IS HEREBY MADE 0 THE ,AN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM rt.. <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: CENSUS TRACT: <br /> OWNER'S NAME: .,a, PHONE: e r `l <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: PIALICENSE # � � PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WEY,L / / PUBLIC WATER WELL / / TEST WELL J / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL L?�l�INDUSTRIAL WATER WELL / J <br /> CATHODIC PROTECTION WELL J // GEOPHYSICAL WELL / OTHER /_7 <br /> NEW WELL: DISTANCE TO EST: SEP= TANK SEWER LIN PIT PR <br /> a <br /> SEWAGE DISPOSAL D CESSPOOL GE PIT 0TH' <br /> REPAIRS: TYPE OF REPAIRS: <br /> A � f <br /> F <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> r <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: iQ I CONTRACTOR: G /da <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY: DATE: �-- <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II PHASE III FINAL -7 <br /> INSPECTION BY: ,�r DATE INSPECTION BY: n-0' DATE 5`�a_ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />