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FOR OFFICES USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 72, <br /> (Complete in Triplicate) Date Issued: �c -7 <br /> XT11IS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> pB$—/70 —01 ; <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 R GULATIONS OF THE, SAN JOAQUIN LOCAL H LTH D STRICT <br /> u✓�...-z�¢-�,;��.t,� � <br /> JOB ADDRESS/LOCA ION: CENSUS TRACT: $ <br /> OWNER'S NAME: PHONE: <br />` <br /> ADDRESS: O CITY: p U—T <br /> CONTRACT O 'S NAME: //L DLA LICENSE # PHONE: — 33 <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL 2& 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: dl <br /> F [w� <br /> �J CP <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 3 <br /> PLOT PLAN:i SHOW ON REVERSE SIDE <br /> I HEREBY CERTI.,THAT I HAVEPREPARED 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 LOCM, HEALTH DISTRICT. <br /> SIGNED: k } ' <br /> 7 �G CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: . Ck/ DATE: <br /> ADDITIONAL COMMENTS: o r <br /> PHASE II - - - PHASE III/FINAL . <br /> INSPECTION BY.: DATE INSPECTION BY: ry - DATE <br /> E H 1426 1 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER -- PINK—CONTRACTOR <br /> F <br />