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E PERMIT NO. L-! 7 .� <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT <br /> (Complete in Triplicate) Date Issued: ' <br /> I 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 AN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 7 3:A 13 / CENSUS TRACT <br /> JOB ADDRESS/LOCATION: L _ - <br /> OWNER'S 'NAME: PHONE: <br /> ADDRESS: 26 51 CITY <br /> CONTRACTOR'S NAME: "LICENSE PHONE,. <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER'WELL Cl- PUBLIC WATER WELL IFII�TEST WELL /- _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / f INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL /_7 GEOPHYSICAL WELL L_/ OTHER <br /> r - <br /> `NEW'WELL:9"DISTANCE TO NEAREST:-.SE IC TANK SE PIT-' <br /> SEWAGE DI FIELD L SEEPAGE PIT OTI <br /> REPAIRS: TYPE OF REPAIRS: LL I <br /> ki <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: Z. <br /> t 1z <br /> PLOT PLAN:' SHOW ON REVERSE SIDE <br /> —I-HEREBY'-CERTIFY�THAT"I•HAVE-PREPARED-THTS A'PPVICATION AND'iHAT'THL`WORK WILL'B Q E 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: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> k APPLICATION ACCEPTED BY: ' DATE: <br /> ADDITIONAL COMMENTS. � <br /> I <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: ,/ DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION. WHITE-DEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />