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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT � -- <br /> (Complete in Triplicate) PERMIT N0. - <br /> THIS PERMIT EXPIRES I YEAR FROM BATE ISSUED Date Issued:/per/3-,� <br /> f APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULE�__AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. IT TO PERFORM <br /> JOB ADDRESS/LOCATION: I19 Z7 <br /> OWNER'S NAME: ENSUS TRACT: <br />' ADDRESS; 7• PHONE: <br /> CONTRACTOR'S NAME: n CITY: � � <br /> LICENSF �PHONE: G yo <br /> i <br /> INTENDED USE: INDIVIDUAL DOMEST WATER WELL _/ PUBLIC WALL TST <br /> TER <br /> WEELL /_7 <br /> CATHODIC P$pTECTZON�W —INDUSTRIAL EWA <br /> TER/ / TER WELL <br /> GEOPHYSICAL W L /7 <br /> � OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK " <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGEERPITNES OTHERT PRIVY Q <br /> pt <br /> REPAIRS: TYPE OF REPAIRS: <br /> ' I <br /> • i <br /> ABANDONMENT/DESTRUCTION: ' METHOD TO BE USED: <br /> F I <br /> S <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> a <br />'I HERE$YRTIFY THAI HAVE'PItEPA12ED THIS APPLIOATION AND THAT"THE WORL WII:L <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE S <br /> `-BE' ONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> AN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: r i <br /> I <br /> J CONTRACTOR: <br />'HASE I FOR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY: ' <br /> ODDITIONAL COMMENTS: j DATE: <br /> PHASE II <br /> "SL�`III/FINAL <br /> NSPECTION BY: DATE INSPECTION Y; <br /> H 1426 SAN :JOA UIN LOCAL HEALTH DISTRICT- DATE I Q -- 1,1--7 <br /> ISTRIBUTION; WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PI - I/72 IM <br /> MACTOR <br />