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FOR OFFICE USE: APPLICATION FOR WELL OR. PUMP PERMIT PERMIT NO. 7 <br /> .(Complete in Triplicate) Date Issued: L i <br /> I THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I 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 /> 1 <br /> j NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH'DISTRICT. <br /> ,TOB ADDRESS/LOCATION: �/ (/ :J' iv n CENSUS TRACT: <br /> OWNER'S NAME: � PHONE: <br /> ADDRESS: rig CITY: <br /> CONTRACTOR'S NAME: LICENSE �7 PHONE:: <br /> INTENDED USE: INDIVIDUAL.-DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL f_1 I.NDUSTR WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCEiTO NEAREST: SEPTIC-TANK%aQ SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD ! CESSPOOL SEEPAGE PIT/ `OTHER <br /> REPAIRS.: TYPE OF REPAIRS: <br /> V <br /> s d 4 <br /> 1 ' - <br /> ABANDONMENT/DESTRUCTION: METHOD TQ 'BE USED: <br /> r <br /> i <br /> k f J1 <br /> PLOT PLAN: SHOW ON REVERSE SIDE a !. <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: t < 1 CZr CONTRACTOR: <br /> } � <br /> f ` 1 <br /> i ` FOR DEPARTMENT USE ONLY <br /> PHASE I; <br /> APPLICATION ACCEPTED"-BY: DATE <br /> ADDITIONAL COMMENTS: -4 _ e ' <br /> I /1to n ar ©rsGLcr�rstic <br /> PHASE Il PHARE III FINAL vvC ' <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 q SAN JOAQUIN LOCAL HEALTH DISTRICT 3/72 IM <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> . �. <br />