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FOR. OFFICE -USE: ;: APPLICATION FOR WELL OR PU11P PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: s--,?-72- <br /> THUS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> I <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON.-III THIS APPLICATION- IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 30B ADDRESS/LOCATION: j faa CENSUS TRACT: 5 3 <br /> OWNER'S NAME: PHONE: <br /> ADDRESS:. zffA G y CITY: <br /> CONTRACTOR'S NAME: �/Y �1 .� �p CpLICENSE # �z PxONE: %��z- ��7 <br />`, INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER. WELLf /INDUSTRIAL WATER WELL <br /> '7ATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 2OL4SEWER LINES PIT PRIVY J ', <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> i <br /> f - i li • S <br /> ABANDONMENT/DESTRUCTION. METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I.I�HAVE PREPARED THIS APPLICATION �ANDITHATsTHE 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 IOCAL HEALTH DISTRICT. <br /> SIGNED: N CONTRACTOR:- <br /> FOR <br /> ONTRACTOR:-FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> _� � 4• <br /> APPLICATION ACCERTED "BY.: — ; DATE _3L7 <br /> 7 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II [III/FINAL <br /> INSPECTION BY: DATE INSPE — ATE <br /> E H 1426 '��' SAN JOAQUIN LOCAL HEAI.TH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEfALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR ' <br />