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FOR OFFICE USE: /^ APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -7 ,>, <br /> (Complete in Triplicate) Date Issued: _?_1 -7 Z <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/LOC ION: ; '2 ',101 CENSUS TRACT: <br /> OWNER'S NAME: PHONE: _ ,Q <br /> ADDRESS: - CITY: 1_0 L) <br /> 'CONTRACTOR'S NAME: c nen) <br /> �) t.,(uidtic� LICENSE 5. 2 PHONE: 6 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /_7 <br /> ' IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL �/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK O SEWER LINESji0t PIT PRIVY ,)O/J L <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT BOTHERij <br /> _ <br /> 4P/SIRS: TY�E OF REPAIRS: � �� � <br /> 1 <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 THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF Q J/pA�j�IN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTHDISTRICT. <br /> SIGNED <br /> SIGNED CONTRACTOR: A) <br /> FOR DEPARTMENT USE ONLY <br /> (PHASE I <br /> APPLICATION ACCEPTED BY: 'Yr . �� 1 T �a ,� DATE: 3 <br /> 'ADDITIONAL COMMENTS: <br /> I ' <br /> PHASE II PHASE III FINAL O <br /> INSPECTION BY: DATE INSPECTION BY: IfDATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />