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r � _ T <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ?L- 6 0 3 <br /> (Complete in Triplicate) Date Issued: <br /> THIS 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/LOCA ION: CENSUS TRACT: 5-S-1 <br /> OWNER'S NAME: 9PHONE: 92 SM34? <br /> ADDRESS: vo WV-,Y CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: 2eo3 <br /> INTENDED USE: INDIVIDUAL DOM TIC 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%SV J SEWER LINES,/1:0_f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/,Zi' CESSPOOL SEEPAGE HIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> eft <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 JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: AACONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEP DATE: (p '� - 7Ij <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> I <br /> INSPECTION BY (L DATE INSPECTION BY: l�� DATE _- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />