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�c- <br /> FOR OFFICE US & : Af?PLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 2 2_. 1cl3 <br /> (Complete in Triplicate) Date Issued: s <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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: CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 72 Jr CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <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 f_1 GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ' <br /> /� N <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: Z" <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 RUL4S AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: ��_„' CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: _l �� DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: / co DATE INSPECTION BY: ATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />