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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -17 <br /> (Complete in Triplicate) , Y : Date Issued: <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> 1 <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORKIISTATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> F <br /> NO. 1862 '':AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> I� <br /> JOB ADDRESS/LOCATION:, _ CENSUS TRACT: <br /> OWNER'S NAME: PHONE: .Ci <br /> E ADDRESSCITY: 7 <br /> CONTRACTOR'S NAME: LICENSE # j�2 7.3 PHONE: s <br /> INTENDED ,USE: INDIVIDUAL DOMESTIC WATWELL / / PUBLIC WATER WELL / / TEST WELL /_ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL Ig INDUS—TRIAL WATER WELL / f <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> i <br /> NEW WELL-.1 DISTANCEST: SEPTIC--I-- . <br /> EPTI ANK SEWER LINES T PRIVY <br /> SEWAGE DISPOSAL CESSPOOL PIT OTHER <br /> 4 <br /> REPAIRS: TYPE OF REPAIRS: Q.' <br /> j ABANDONMENT/DESTR CTIQN: METHOD,'TO BE U : <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> J <br /> i I HEREBY (CERTIFY THAT I HAVE PREPARED THIS-APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> I ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY oil <br /> JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: I ,� CONTRACTOR: ✓ <br /> _ .r110 _ <br /> tv <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY: <br /> I DATE <br /> �._ <br /> ADDITIONAL COMMENTS: <br /> I • <br /> t <br /> F PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE 7 <br /> (. E H 1426 1tLw I SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M . <br /> DISTRIBUxiION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK--CONTRACTOR <br />