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FOR OFFICE USE; 1 P BERM/ APPLICATION FOR WELL OR PUMP �� PERMIT N0 <br /> a I . <br /> T S PERMIToEXPIRESin Yriplicate) Issued-21--j-0 J7/ <br /> Date Iss�ed�3_ ? <br /> EAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTHsDISTRICT FOR A <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE N COMPLIANCE WITH `COUN TY ORDNANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DIS PERMIT TO PERFORM <br /> JOB ADDRESS/LOCATION: �rY4 TRICT. <br /> OWNER'S NAME: r o S`C c f <br /> CENSUS TRACT: <br /> ADDRESS: o <br /> CONTRACTOR'S NAME: PHONE: <br /> CITY: <br /> INTEND <br /> LICENSE # $ G1 PHONE: <br /> INDIVIDUAL INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /� T <br /> r <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / TIDUSTRIALEWATERLWELL/ <br /> CATHODIC PROTECTION WELL <br /> /% GEOPHYSICAL WET7L / / <br /> OTHER <br /> NEW WELL: DISTANCE TON <br /> SEWAGE DISPOSAL FIELD SEPTIC TANK SEWER LINES - <br /> CESSPOOL SEEPAGE PIT —OTHER - <br /> REPAIRS: <br /> �-- PIT PRIVY <br /> OTHER ' <br /> S <br /> REPAIRS: TYPE OF REPAIRS: <br /> t <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED; <br /> � f <br /> j <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> C HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL f <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br />;OUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT <br />;IGNED: <br /> CONTRACTOR <br /> HASE I FOR DEPARTMENT USE ONLY <br /> A <br /> PPLICATION ACCEPTED BY: 9 { <br /> DDITTONAL COMMENTS: DATE: <br /> PHASE IT <br /> PHASE II FINAL <br /> fSFECTION BY: SATE <br /> H 1426 INSPECTION BY: DATE <br /> STRIBUTION: WHITE- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> HEALTH DISTRICT -- <br /> 1172 1M <br /> YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />