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FOR OFFICE USE: XA L(2-P <br /> APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' o q <br /> (Complete in Triplicate)P ) Date Issued: }1�3 -"7�v <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 /> I THE WORK-STATED-HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> f NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> ' Y <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: <br /> OWNER'S NAME': PHONE: _ 3 <br /> ADDRESS: ' CITY: <br /> CONTRACTOR'8 NAME: <br /> LICENSE # ,2e� 3 PHONE <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WLL PUBLIC WATER WELL /% TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDU�§TTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL WELL L_/ OTHER f7 <br /> .sp <br /> . i <br /> NEW WELL: DISTANCE NEAREST: SEPTI SEWER LINES_ _ PIT P lAV <br /> SEWAGE DISPQ FIELD CESSP EEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> Q <br /> W <br /> r ' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> f <br /> 1 <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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I �- <br /> APPLICATION ACCEPTED BY V. DATE: <br /> �- <br /> ADDITIONAL COMMENTS: • <br /> PHASE II PHASE III/FINAL ,+ <br /> INSPECTION BY: DATE INSPECTION BY: DATE -3 <br /> E H 142E <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR ! <br />