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e3,11 C, ` 7z466 .P <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 2-- V3 J <br />` (Complete in Triplicate) Date Issued: -s <br /> X, '" THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT -FOR A PERMIT TO PERFOPM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> %,1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCATHEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: - L / D CENSUS TRACT: <br /> OWNER'S NAME: Ul r PHONE:- <br /> ADDRESS: <br /> HONE:ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /VT PUBLIC WATER WELL f_1 TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / 4 <br /> s <br /> NEW WELL: DISTANCE TO NEAREST: SEPTId-TANK*'1 ,SEWER LINES PIT PRIVY - <br /> I SEWAGE DISPOSAL FIELD— CES SPOOi; SEEPAGE,PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: j <br /> - A6 <br /> ABANDONMENT/DESTRUCTION:' METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> s ' <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 /> iL„• 3 <br /> , <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> a� <br /> APPLICATION ACCEPTED BY: DATE: S— VAa <br /> ADDITIONAL COMMENTS:, <br /> �4 <br /> cf <br /> PHASE II PHASE III FINALS <br />*;INSPECTION BY: DATE _ INSPECTION BY:-,- DATE 2, <br /> ETH 1426 x: SAN JOAQUIN LOCAL HEALTH DIST C -1172 1M <br /> DISTRIBUTION: WHITE=HEALTH DISTRICT —YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />