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FOR OFr-,IGE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. .[LT�' . <br /> (Complete .in Triplicate) Date Issued: 3_ 7 a.T-L, <br /> THIS PERMIT EXPIRES' l 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 /> 8�'J lam` <br /> JOB ADDRESS/LOCATION: ENSUS'TRACT:. <br /> OWNER'S NAME: PHONE <br /> ADDRESS: J}.`CP �,, ,� CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: IND IDUAL .DOMESTIC WATER WELL,/ / PUBLIC WATER W / / .TEST WELL / / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / .TNDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <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: <br /> C <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> k <br /> IE PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILLBE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF S JOAQUIN, AND, THE LES AND REGULATIONS OF THE SAN JOA�UIN LOCAL HEALTH DISTRICT. <br /> SIGNED: <br /> tilt"AP ONTRACTOR: <br /> } FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BX: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II x PHASE III FINAL <br /> INSPECTION BY: DAl'E INSPECTION BY: 7f DATE <br /> C� <br /> IM <br /> '-E H 1426 SAN JOAQUIN LOCAL HEALTH'DISTRICT 1/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -• YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />