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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. -22-- <br /> (Complete in Triplicate) Date Issued: <br /> H PERMIT EXPIRES I YEAR FROM DATE ISSUED �6, �� ~ <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 /> T 44 <br /> ;SOB <br /> ADDRESS/LOON: " ,i,ce u CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> CONTRACTOR'S NAME: �« i / � CITY: <br /> r,� r LIC�SE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL , PUBLIC WATER WELL / J TEST WELD. / <br /> IRRIGATION/LIVESTOCK/AGRICULTU L WATER WELL INDUSTRIAL WATER WELL J / <br /> CATHODIC PROTECTION WELL. /-/ GEOPHYSICAL WELL % / OTHER / N <br /> � L��// <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK -SSEWER` LINES PIT PRIVY r <br /> SEWE DISPOSAL FIELD , CESSPOOL SEEPAGE PIT,�jI OT R <br /> ° e J ,��f <br /> p ' 4 t�litJ � Y-�'v L% <br /> REPAIRS: <br /> A ONMENT/DESTRUCTION: METHOD TO BE USED I- � <br /> - n <br /> PLOT PLAN: SHOW ON REVERSE SIDE 1y �� <br /> I HEREBY,.CERT-IFY THAT. I HAVE-PREPARED;THIS:AP-PLICATION-.-AND-THAT THE:WORK-WILL BES-DONE <br /> ACCORDANCE WITH THE PROVISIONS OF THE -LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES'OFxTHE <br /> COUNTY OF SAN AQUIN, AND THE ULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH ISTRICToµ.� <br /> SIGNED. <br /> CONTRACTOR: <br /> FORDEPAR7MENTtUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: BATE: tZs 71, f <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY; DATE <br /> E H 1426 _ <br /> SAN_JOAOUIN ;LOCAL'HEALTH_ DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> U <br />