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g � � <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 7 <br /> L' 7 2 (Cam Tete' in Triplicate) Date Issued: �_ S.'-7 �. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED - '- <br /> APPLICATION IS HEREBY DE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FORA PERMIT TO PERFORM p <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND R GULATIONS OF TH J U�1 O& HEALTH DISTRICT. <br /> I, ?L {p 3 <br /> /LOCATION: .. CENSUS TRACT: <br /> OWNER'S NAME: PHONE: ' <br /> ADDRESS: " ; CITY: <br /> CONTRACTOR'S NAME: "" IGENSEPHONE: f <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICUL L WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f / GEOPHYSICAL WELL / / OTHER <br /> 3 <br /> NEW WELL: DISTANCE TO NEAREST: SEPT3,C TANK/D!3 SEWER LINES !' PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD lep CESSPOOL SEEPAGE PIT -/--OTHER] <br /> REPAIRS: TYPE{OF REPAIRS: <br /> -- 4 <br /> 5 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED. ' ► <br /> i <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 /> i <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. i <br /> 7 f � <br /> SIGNED: — 9 -� T ,. - -CONTRACTOR e _ <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY: , DATE: 'aS <br /> ADDITIONAL COMMENTS: <br /> Q <br /> PHASE IT PHASE III FINAL <br /> I <br /> INSPECTION BY: / DATE may- Y INSPECTION BY: '�i DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/7.2 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />