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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. .3 <br /> (Complete in 'Triplicate) Date Issued: ' , v <br /> ` THIS PERMIT EXPIRES I 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 /> JOB ADDRESS/LOCATION: ' c ' h��� s� � � CENSUS TRACT: <br /> OWNER'S NAME: i19,1PHONE <br /> ADDRESS: b, a CITY: <br /> CONTRACTOR'S NAME: LICENSE /9,:3U PHONE: 44a I--7e.76 <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL L-7 PUBLIC WATER WELL / / TEST WELL /� <br /> F IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL ly INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL .]/ OTHER / / <br /> ' .NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: T c r _ �- <br /> k <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ,t- <br /> w � <br /> PLOT PLAN: ' SHOW ON REVERSE SIDE <br /> r 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, THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 5IGNID <br /> CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED BY: + �- '� <br /> DATE: � l <br /> ADDITIONAL COMMENTS: <br /> I <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: N N� DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICf4 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR C <br />