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FOR" OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT <br /> PERMIT NO. Z�-Z-,I <br /> (Complete in Triplicate) Date Issued: ?y <br /> TIS PERMIT EXPIRES 1 YEAR FROM DAZE 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 /> r <br /> JO$ ADDRESS/LOCAT ON q,•- 1 e Ad <br /> t OWNER'S NAME: �'�'' o SUS TRACT: <br /> E ADDRESS: PHONE: <br /> CONTRACTOR'S NAME: LICENSE # CITY: <br /> _c3PHQNE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL Aff PUBLIC WATER WELL El- TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL // OTHER --- <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK - ` <br /> SEWAGE DISPOSAL FIELD ��SEWER LINES PIT PRIVY <br /># l CESSPOOL SEEPAGE PIT OTHER, �I <br /> k <br /> E REPAIRS: TYPE OF REPAIRS: <br />' X111 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE ' <br /> USED: <br /> PLOT PLAN; SHOW ON REVERSE SIDE ' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION'AND THAT THE�.WQRK WIIL E DONE IN ' <br />, LIFORNIA <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF.j0A ,\,THE .ORDI <br /> COUNTY OF SAN JOAQUIN, AND NANCES' OF' THELES AND REGULATIONS OF`THE SAN J6AQ6-IN LOCALTH ICT' y � d <br /> M��'I vµ ALL DISTRICT' <br /> SIGNED: Y-SUPAO / � ���"7i! '�•� 1i'�""� f� � <br /> CONTRACTOR:ZN <br /> PHASE I <� FOR DEPARTMENT'USE .,OO LY <br /> APPLICATION ACCEP • - <br /> ADDITIONAL COMMENTS: ,� _- DATE - <br /> PHASE II PHASE III FINAL` <br /> INSPECTION BY: I DATE 3-Y3 -7 z INSPECTION BY: (� DATE -- <br /> E H 1426 C .r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> DISTRIBUTIONg�72 s <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - 'YELLOW-PROPERTY' ©WNER 7�PINK-CONTRACTOR S <br />