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f <br /> FOR 0=F2CE 06E` APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: 7� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY - DE 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/LO TION s' �' CENSUS TRACT: S �' <br /> OWNER'S NAME: PHONE: 0 347 <br /> ADDRESS: S CITY: _ <br /> CONTRACTOR'S NAME: LICENSE �,fC36�/�� s'PHONE: � <br /> INTENDED USE: INDIVIDUAL V_'T <br /> C WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL fi7l_ INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER <br /> t <br /> NEW WELL: DISTANCE TO NEAREST: —SEPTIC TANK- ,= SEWER LINES'""`- PIT PRIVY�"""""�` <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> r <br /> REPAIRS: TYPE OF REPAIRS: <br /> ,Z <br /> M <br /> f ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> f <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> w 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,�---TffE-ORDINANCE5'OU THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: Ile <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> J <br /> APPLICATION ACCEPTED BY: �� ; J f. DATE: <br /> • ADDITIONAL COMMENTS: ` <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE % ~ 7?/ <br /> E H 1426 . SAN.JOA UIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR Gift <br />