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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. _ 7 Z-Z � <br /> (Complete in Triplicate) Date Issued: Z-ti 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 T ON: P$r, 0`� �~ CENSUS TRACT- <br /> OWNER'S NAME: o , PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTO '6 14AME: 7LICENSE # 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 f_1 GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTI TANK � SEWER LINES (� PIT PRIVY <br /> ,E <br /> SEWAGE DISPOSAL FIELD `ACESSPOOL SBATHER <br /> PIT HER <br /> REPAIRS: TYPE OF REPAIRS: A51' .6747dill <br /> eA WC G a h e-e4t Z, �)-I O <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 SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: _ CONTRACTOR: <br /> a � <br /> O DEPARTMENT USE ONLY <br /> PHASE I <br /> Alg <br /> APPLICATION ACCEPTED BY: DATE: _.2f7,7 <br /> ADDITIONAL COMMENTS: <br /> ,,7...._ <br /> PHASE II P S II FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE _ 3—2-3 Y <br /> E H 1426 . SAN JOA UIN LOCAL HEALTH DISTRIC 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - INK-C CTOR <br />