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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP 'PERMIT PERMIT NO. _// <br /> (Complete in Triplicate) Date Issued: 3- - � L <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: r PHONE: <br /> ADDRESS: ,2 z CITY: <br /> CONTRACTOR'S NAME: <br /> LICENSE L,() 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 /—/ GEOPHYSICAL WELL / / OTHER %/ <br /> C <br /> I <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK ® SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> N <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I <br /> i <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> t <br /> i <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 /> SIGNID: �� CONTRACTOR: ;f�� �� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: 1 <br /> ADDITIONAL COMMENTS: <br /> DATE: <br /> R ' <br /> f <br /> PHASE II - - <br /> PHASE III/FINAL <br /> INSPECTION BY: DATEp <br /> INSPECTION BY: �/. DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR X72 1M <br />