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C,&-q <br /> FOR OFFICE USE: APPLICATIA FOR WELL OR PUMP PERMIT PERM <br /> (Complete in Triplicate) Date k ta- <br /> THIS <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY FADE 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/LOCATI : CENSUS TRACT: + � <br /> OWNER'S NAME: r PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: DLI&&L LICENSE PHONE: <br /> /30 -4 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL f_1 TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /'_INDUSTRIAL WATER WELL / J <br /> uATHODIC PROTECTION WELL /_/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 4SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ,, <br /> (_3 . <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 jJOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL <br /> —HEALTH DISTRICT. <br /> r CONTRACTOR: <br /> SIGNED: ^, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �. DATE: '' 717 2-- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY• `4� DATE ---L- -' <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT ^T 1/72 IM <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />