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FOR OFFICE USE: (OAPPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �, <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: 107 O - / CENSUS TRACT: <br /> OWNER'S NAME: PHONE <br /> ADDRESS: o CITY: <br /> CONTRACTOR'S NAME: LICENSE #/I3 3T PHONE: 3 <br /> i3 v 'ov- <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 /-7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: _ 12--�� <br /> J <br /> t,7 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: y <br /> d <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: eiC54� "'z- CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f����1 <br /> APPLICATION ACCEPTED BY: - <br /> „ DATE: <br /> ADDITIONAL COMMENTS: �— ,T— <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: A�_. DATE,°' <br /> E H 1426 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />