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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 L-17 <br /> (Complete in Triplicate) Date Issued: <br /> 419 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�JTHEAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> �� CENSUS TRACT: <br /> JOB ADDRESS/LOCATION: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 41AbtT CITY: _ 1� <br /> QNTRACTOR'S NAME: -LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /TEST WELL / / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> _T <br /> _AN <br /> - _.- <br />"NEW`WELL: DTSTANCE TO NEAREST:�.SE IC TANK u S PI VY <br /> SEWAGE DIS FIELD OL SEEPAGE PIT OTHER <br /> �AL ) <br /> REPAIRS: TYPE OF REPAIRS: GaG <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: , <br /> # 1.4 <br /> —C� <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br />--I—HEREBY^CERTIFY-THAT-I• HAVE-PREPARED`THIS—APPVtCATION AND-THAT THENORK 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I J �, - <br /> / X 'I <br /> APPLICATION ACCEPTED BY: '�� DATE: <br /> ADDITIONAL COMMENTS: i <br /> PHASE III FINAL <br /> PHASE II _ <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 lM <br /> DISTRIBUTION. WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />