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FOR OFFICE USE: � A PLICATION FOR WELL OR PUMP PETt�i T PERMIT NO. 7 L- 3 � S <br /> (Complete in Triplicate) Date Issued: ��Z <br /> HTS PERMIT EXPIRES I 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: /-L4 y CENSUS TRACT: <br /> OWNER'S NAME: PHONE: -'3/ 2 C 3 � <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: _ � ��(/ jr ra ,LICENSE # GLG�r 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 /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK Ld SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> N vs tEgEj,2,q . <br /> REPAIRS: TYPE OF REPAIRS: <br /> • Cr' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> :PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH HE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN AQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> � <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �/�/_� ► V o-"�.� DATE: �. - <br /> ADDITIONAL COMMENTS: <br /> PHASE II. PHASE III/FINAL <br /> INSPECTION BY: DATE 7[ INSPECTION BY: ` DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK--CONTRACTOR <br />