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FOR OFFICE USE: APPLICATION FOR WELL OR.PUMP PERMIT PERMIT NO. 7Z —( 6 <br /> — (Complete jn,.T-riplicate) Date Issued: 3, z —q z <br /> T IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO 'THE `SAN�JOA UIN LOCAL'HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. 'THIS`APPLICATION IS-r;4DDAIN COMPLIANCE WITH COUNTY ORDINANCE , <br /> NO. 1$62 AND RULES AND REGULATIONS OF THE SAN _JOAQUIN LOCAL HEALTH DISTRICT. ` ry <br /> JOB ADDRESS/LOCATION: CENSUS TRACT:;._ -- -- � <br /> t OWNER'S NAME: PHONE: <br /> ADDRESS; -CITY: <br /> CONTRACTOR'S NAME: LICENSE # -- — PHONE: Y <br /> INTENDED USE; INDIVIDUAL DOMESTIC.-WATER;WELL /_./ -PUBLIC:_WA..TER LL / / -TEST .WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TAN&)p0 SEWER LINES PIT PRIVY <br /> SEWAGE--DISP.OSAL FIELD---7po— CESSPOOI; 'SEEPAGE' PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> 6' <br /> ABANDONMENT/DESTRUCTION: METHOD TO 'BE USED: <br /> < " <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THATI HAVE PREPARED;THIS- APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> E' <br /> ACCORDANCE WITH THE PROVISIONS OF THLAWS OF_THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND T RULES"AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT: <br /> Y <br /> SIGNED: CONTRACTOR: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED BY: DATE: —.2 _�� <br /> ADDITIONAL COMMENTS: <br /> — — — — -- <br /> I WRA, NO'S"`- 6 R D V 7 E -- 16 RflYLt_L.. r1t CSG�. �- • ONL.Y. <br /> ^ PHASE II -— . 'PHASE III/FINAL <br /> INSPECTION BY; .L DATE M. �� INSPECTION BYY:4. DATE — .'2 <br /> E H 1426 "":—SAN"JOAQUIN LOCAL HEALTH DISTRICT 1/72" IM <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />