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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP'PERMIT PERMIT NO. L- /�( <br /> 4 (Complete in Triplicate) Date Issued: <br /> S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE 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 _E,SAN� JaAQUIN LOCAL HEALTH DISTRICT. <br /> Com-(' -t2 <br /> JOB ADDRESS/LOCATION: '� « CENSUS TRACT: <br /> OWNER'S NAME: PHONE: j, 7S-,,Y-- 7 <br /> ADDRESS: ,� CITY: <br /> CONTRACTOR'S NAME: i111-IL—t <br /> a LICENSE #7� ,p PHONE: <br /> f/✓ _ _ _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / /' •PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL A71 INDUSTRIAL WATER WELL <br /> 3 CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER L/ <br /> NEW WELL: DISTANCEITO -NEAREST,: , EPTIC TANK- '':.SEWER 'LINES V PIT PRIVY- <br /> SEWAGE DISPOSAL FIELT3� CESSPOOL SEEiAGE"PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD BE-iISRD: <br /> i <br /> I <br /> xg <br /> r PLAT PLAN: SHOW ON REVERSE SIDES(lu, <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.fTHE <br /> COUNTY OF SAN J.OAQUIN,• AND THE RULES AND REGULATIONS OF.'THE SAN JOAQUIN. LOCAL HEA"D�,ISSIGNED: ', _ \ ,CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY «... <br /> i� PHASE I <br /> I APPLICATION ACCEPTED BY: DATE: 1-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE el <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />