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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. `7 y .Z1.0_ <br /> (Complete in Triplicate) Date Issued: ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> P <br /> t <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: 3011 .r' F (6fE %�4 "�� CENSUS TRACT: <br /> OWNER'S NAME: Tr - PHONE: <br /> CITY: ' <br /> ADDRESS: IC 7 � <br /> f <br /> CONTRACTOR'S NAME: ,6 � w -- LICENSE # PHONE: Ste•. <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL I I <br /> CATHODIC PROTECTION WELL / I GEOPHYSICAL WELL I I 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: 1 G` �f <br /> ABANDONMENT/DESTRUCTION: METHOD -TO BE USED: {{{ <br /> - z N <br /> PLOT PLANT 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 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: � s7'� �� CONTRACTOR: A/o h <br /> FOR DEPARTMENT USE ONLY <br /> ` PHASE I _ O <br /> APPLICATION ACCEPTED BY: iii — — DATE: <br /> ADDITIONAL COMMENTS: <br /> s � — <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: �`� DATE INSPECTION BY: '` DATE -% <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DI_STRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER --PINK=CONTRACTOR <br />