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"FOR OFFICE USE• APPLICATION .FOR WELL' OR PUMP PLRMIT PERMIT NO. _]Z-'16_' <br /> (Complete in '.Triplicae) Date Issued: 3 <br /> THIS 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 THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> s d : <br /> JOB ADDRESS/LOCATION: - � CENSUS TRACT, <br /> -- -• a�� <br /> OWNER'S NAME: / = e � _ <br /> ADDRESS: CITY: L�SCAA•s'rI <br /> CONTRACTORS NAME: 5�+7 <br /> s.-' j ' _ LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL ,DOMESTIC-WATER:.,WELL.:-/PUBLIC WATER WELL / / TEST WELL4. <br /> / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL L// GEOPHYSICAL WELT, ,/ / OTHER <br />� f <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .. - <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT; OTHER <br /> REPAIRS." TYPE OF REPAIRS .l 1 l►/ S tl f'� �` <br /> ` ABANDONMENT/DESTRUCTION: METHOD TO BE USED: C <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 JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> -� CONTRACTOR: <br /> SIGNED: . <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE: Z Z <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: y <br /> PHASE III FINAL <br /> PHASE II <br /> INSPECTION BY: t DATE � �� <br /> �1� INSPECTION BY: DATE <br /> E H 1426 IM <br /> `SAN JOAQUIN LOCAL HEALTH'DISTRICT 172 <br /> PINK CONTRACTOR <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - a <br />