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f FOR OFFICE USE: APPLICATION FOR WELL OR PERMIT NO. Ti `.I.y D <br /> (Complete in Triplicate) Date Issued: <br /> T IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN �/AQUIW "LOCAL HEALTH 'DISTRICT FOR A PERMIT TO' PERFORM E <br /> k 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 /> JOB ADDRESS/LOCATION: ,�L le CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: pA., CITY: <br /> CONTRACTOR'S NAME: .VCEYSE PHONE: <br /> INTENDED USE: INDIVIDUAL DOMEST C WATER WELL / / /PUBLIC WATER WELL / / TEST WELL / _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL X INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SPPTIC TANK,.5D SEWER LINES ,,J Cl PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4ESSPOOL SEEPAGE PIT OTHER' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY'CERTIFY THAT I HAVE PREPARED THIS-APPLICATIONAND�THAT THE WORK WILL BE DONE IN <br /> ACCORI?ANCE"WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOA IN, AND THE RULES REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: r CONTRACTOR: _ <br /> FOR DEPARTMENT :USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS. <br /> PHASE II PHASE III FINAL y _� <br /> INSPECTION BY: DATE _-_ INSPECTION BY: DATE ' <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M . <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />