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FOR OFFICE .ddSE: • Y'r , <br /> APPLICATIflNvFOR WELL QR PUMP, PERMIT PERMIT NO, <br /> (Camp leie,in°Tripli'ca.te} Date Issued: " -� . <br /> TRIS PERMIT EXPIRES `1 YEAR FROWDATE ISSUED <br /> APPLICATION IS HEREBY MADE TO 'THE SAN JOAQUIN LOCAL;HEALTH DISTRICT FORA PERMIT TO,PERFORM <br /> THE WORK STATED HEREON." !'THIS f`APPLIdkTl6N IS.MADE IN-COMPLIANCE WITH`C6UNTY ORDINANCE <br /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> JOB ADDRESS/LOCATION: �j S-�` A �' <br /> _ DLA CENSUS TRACT.: <br />` OWNER'S NAME: _ /� 1�-T-� PHONE: <br /> ADDRESS: �.. „__ 'CITY: (V�AT�C f} <br /> CONTRACTOR'S NAME: s LICENSE # PHONE: <br /> INTENDED USE: - INDIVIDUAL.DOMESTIC- WATER-WELL-/ --PUBLIC_:WATER WELL / / TEST WELL _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL <br /> w <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER f / <br /> r � <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK Z-SEWER LINES 3-0 ,r PIT PRIVY MM_L/ r <br /> SEWAGE DISPOSAL FIELD�-1-CESSPOOL SEEPAGE PIT /QA-TR—)THER <br /> e <br /> REPAIRS: TYPE OF REPAIRS: f <br /> ABANDONMENT/DESTRUCTION: METHOD TO 'BE USED: C <br /> Z G <br /> f\rcC <br /> i <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: CONTRACTOR: <br /> PHASE $ FOR DEPARTMENT USE ONLY <br /> .APPLICATION ACCEPTED <br /> ,ADDITIONAL COMMENTS DATE: <br /> SOt <br /> PHASE II . PHASE III/FINAL <br /> E <br /> INSPECTION BY: DATE - INSPECTION BY.: = DATE <br /> E H 1426 - •, <br /> . SAN UOAQUIN LOCAL HEALTH .DISTRICT ` - 1/72-1M N <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />