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fl- <br /> FOR OFFICE- USE: 4 <br /> APPLICATION FOR WELL OR PUMP <br /> PE <br /> RMIT <br /> (COmple'te in Triplicate) PERMIT NO. Z 2. <br /> THIS PERMIT EXPIRES I' YEAR FROM DATE Date Issued: -_Z <br /> ISSUED �.ZIc <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL � <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN <br /> OMPLIANCE WIT FORA P <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH PERMIT TO PERFORM <br /> WITH COUNTY ORDINANCE <br /> JOB ADDRESS/LOCATION� DISTRICT, <br /> OWNER'S NAME: s 3 �� r <br /> ADDRESS: CENSUS TRACT: <br /> CONTRACTOR'S NAME; PHONE: <br /> �� k, Jd n LICENSE <br /> CITY, <br /> INTENDED <br /> INTENDED USE: � _ PHONE: <br /> INDIVIDj <br /> UAL DOMESfiTC- WATER WELL /_/ PUBLIC WATER WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL // TEST WELL /� <br /> CATHODIC PROTECTION WELL /_INDUSTRIAL WATER WILL <br /> // GEOPHYSICAL WELL / / OTHER <br /> - CiF WELL: D I STANCEEARE <br /> TON <br /> SEWAGE DISPOSAL FIELD SEPTIC TANK SEWER LINES _ <br /> PIT PRIVY <br /> CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> � e <br /> • A <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> C HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK#WILL BE DONE IN <br /> LCCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA <br /> A -THE ORDINANCES OF THE AUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. 4) <br /> IGNID: C <br /> CONTRACTOR: F� i <br /> k <br /> HASE I FOR DEPARTMENT USE ONLY z <br /> PPLICATION ACCEPTED BY: <br /> DDITIONAL COMMENTS: DATE: —.2 or y <br /> PHASE II <br /> PHASE III/FINAL <br /> FSPECTION BY: /i/ DATE <br /> H 1426 INSPECTION BY: �° DATE BY: - <br /> -Z <br /> SAN JOA UIN LOCAL HEALTH DISTRICT IM <br /> WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER' -• PINK-CONTRACTOR i/ <br />