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y „ <br /> FOR OFFICE USF ' APPLICATION FOR WELL OR PUNY PERMIT PERMIT NO. 72_ 6 S 3 <br /> (Complete in Triplicate) Date Issued: 2-_:?. -7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATIO S 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/LOCATIION: r `' <S �c / t' ' CENSUS TRACT: <br /> OWNER'S NAME: _ % � PHONE: '> <br /> ADDRESS: - . r CITY: <br /> CONTRACTOR'S NAME: , F;. LICENSE # � -�-L PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL { PUBLIC WATER WELL / / TEST WELL /? <br /> IRRIGATION/LIVESTOCK/AGRICULT L 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 SEEPA PIT OTHER <br /> tol <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 OAQUIN, AND E RULES AND REGULATIONS OF THE SAN JOAQUIN- LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: -41� -� <br /> J <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �) <br /> APPLICATION ACCEPTED BY: ', �i� DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: �� DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />