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APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 j <br /> FOR OFFICE USE ' <br /> (Complete in Triplicate) Date Issued: 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r a <br /> APPLICATION I5 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. 1$52 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CENSUS TRACT: <br /> JOB ADDRESS/LOCAT N:,� PHONE: <br /> ;OWNER'S NAME' " ' '` CITY: <br /> ADDRESS: + '` <br /> CONTRACTOR'S' NAME• r LICENSE # PHONE: <br /> ------- <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL X1 PUBLIC WATER WELL/ / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL. WATER WELL / / INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL Ll GEOPHYSICAL WELL 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: . <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> Y <br /> PLOT PLAN: SHOW ON REVERSE SIDE m <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 LOCHEALTH DISTRICT. <br /> CONTRACTOR- <br /> SIGNED: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II - • - 4 PHASE III/FINAL <br /> ,. , . .rE 7 <br /> INSPECTION BY: DATE INSPECTION BY: c <br /> E H 1,425 T SAN JOA VIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />