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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> ,f (Complete in Triplicate) Date Issued: <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: S <br /> OWNER'S NAME: ! PHONE: <br /> ADDRESS: "" i / CITY: <br /> CONTRACTOR'S NAME: t � LICENSE It 1l/_/�j PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / -/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / J OTHER / / ; <br /> 09 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _4� <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> a <br /> REPAIRS: TYPE OF REPAIRS: <br /> f . <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; ,+�,1'.� F f�• (s� '�� CONTRACT'OR: � J �i 0 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED. BY: ��„ , DATE: �ia '7v <br /> ADDITIONAL COMMENTS: - <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE %� f1'�� <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> f-DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />