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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT <br /> k PERMIT NO. <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <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 /> 4 NO. 1562 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> A .77y <br /> JOB ADDRESS/LOCATION: } CENSUS TRACT: <br /> OWNER`S NAME: �-, PHONE: 2 -3 <br /> ADDRESS: - lii9®.-fG CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /% TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /—INDUSTRIAL WATER WELL /_7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L_1 OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES SZ /PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD ,_0/CESSPOOL SEEPAGE PIT OTHER <br /> f <br /> F REPAIRS: TYPE OF REPAIRS: <br /> .J <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I <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 /> SIGNED: CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> t APPLICATION ACCEPTED BY: <br /> DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIT FINAL <br /> INSPECTION BY: _ DATE INSPECTION BY: DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 ISI <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />