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FOR OFFICE USE: APPLICAT FDR WELL OR PUMP PERMIT PERMIT NO. L- 7 <br /> . <br /> (Complete in Triplicate) Date Issued: Z-L -I v <br /> THIS 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 THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: Q7-5 7 Id��;�� �_,,�e� J�c.E -- - _ CENSUS TRACT: <br /> OWNER'S NAME: —x - PHONE: <br /> ADDRESS: 7 CITY:CONTRACTOR'S NAME: LICENSE # <br /> PHONE: <br /> INTENDED USE: INDIVIDUAL DOMEST C WATER WELL /)C/ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRCULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHICAL WELL / / OTHER /-7 <br /> NEW WELL: DISTANCE T EAREST: SEPM TANK EWER LINES _PIT PRIVY ! <br /> SEWAGE DISPO IELD CES P©OL SEEP`41- I� OTHER- <br /> REPAIRS: TYPE OF REPAIRS: - <br /> NNN <br /> { <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USE : <br /> l <br /> E <br /> J <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THS APPLICATIONAND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS 0 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: /fir �..c� rn_ _ . <br /> FOR DEP ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: / DATE: .Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: R- DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOC HEALTH DISTRICT 102 <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PR RERTY OWNER — PINK—CONTRACTOR <br />