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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z 5 <br /> (Complete in Triplicate) Date Issued: '7 Z-,- <br /> THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> i <br /> APPLICATION IS H&REBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATEDAEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> ,TOB ADDRESS/LOC ION: ] � &k NSUS TRACT: <br /> OWNER'S NAME: / PHONE'. p 71 -- <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE #/ 13 PHONE: C � f.- <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /—/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL f_1 <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> f <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> b <br /> REPAIRS: TYPE OF REPAIRS: c � <br /> IF ff ell <br /> m <br /> 4 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 0 <br /> l <br /> 1 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> s <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLI'CATION 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 /> SIGNED: - CONTRACTOR: /J <br /> FOR DEPARTUENT USE ONLY <br /> PHASE I <br /> Yr <br /> APPLICATION ACCEPTED BY: DATE: Z <br /> ADDITIONAL COMMENTS: <br /> G <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE ' <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />