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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 7 <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED q `f y 'f v <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: 19645 S. Sexton CENSUS TRACT: <br /> OWNER'S NAME: Joe Fu ric e11 i PHONE: F-38-301.6 <br /> ADDRESS: G An P CITY: Escalon <br /> CONTRACTOR'S NAME: John Pane ro LICENSE # 1 20 7 c PHONE: - 00 <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /X/ 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: <br /> t <br /> E <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED- <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> 1-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 SPATE 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 r -- <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE IIIII l/FINAL <br /> INSPECTION BY: DATE INSPECT ON B DATE <br /> R E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 72 1M <br /> ' DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />