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FOR OFFICE USE: ,.= APPLICATION,FOR WELL OR PUMP PERMIT PERMIT N0. <br /> �✓ (Complete ,in ,,Triplicate) Date Issued: v <br /> T IS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED <br /> APPLICATION IS HEREBY.MADE TO `THESAN}JOAQUIN LOCAL HEALTH DISTRICT FOR A ,PERM7:T, TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS'MADE IN COMPLICE WITH'COUNTY ORDINANCE <br /> AN " l <br /> NO. 1862 AND RULES AND REGULATIONS,OF THE .SAN 'JOAQUIN LOCAL. HEALTH .DISTRICT.-"- <br /> Vil <br /> JOB ADDRESS/LOCATION: �� �iLC7-rtl+ fti{ */ Z� CENSUS TRACT: Y <br /> OWNER'S NAME 1 PHONE ; _- , - <br /> ADDRESS: 1311 e�IP 0-k�)e:0!�4u 04 yo -. - - - -- CITY: _ <br /> CONTRACTOR'S NAME:­-7 LICENSE ;<� PHONE: ' <br /> e _ _ <br /> INTENDED USE: INDIVIDUAL .DOMESTIC. WATER WELL;/ PUBLIC WATER WELL / ./. 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 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> m <br /> F REPAIRS: TYPE OF REPAIRS: T <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> s <br /> a <br /> f <br /> p i <br /> { PLOT PLAN: SHOW ON REVERSE SIDE <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: �Q CONTRACTOR: <br /> i <br /> f <br /> G ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: v <br /> PHASE II PHASE III FINAL <br /> I� INSPECTION BY: DATE INSPECTION BY: (� DATE' — �-�-- <br /> € E H 1426 SAN MAMO_LOCAL`HEALTH DISTRICT 1/72 IM <br /> F DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />