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ti <br /> FOR OFFICE USE: Ak, .iCATION{FOR WELL OR PUMP PERMIT PERMIT N0. <br /> {Complete in,Triplicate <br /> Date Issued: Z^2r � <br /> ) 7 <br /> 4. �. 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 /> o - <br /> JOB ADDRESS/LOCATION:' `3 .,� . 9_0 CENSUS TRACT: <br /> OWNER'S NAME: l PHONE:_ <br /> ADDRESS: / y 'CITY: <br /> CONTRACTOR'S NAME: (a( :n ` LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC- WATER WELL / -:PUBLIC WATER WELL -/. / TEST. WELL 1_7 <br /> IRRIGATION/LIVESTOCK%AGRICULTURAL WATER WELL /- INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 5'0 � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 5�b CESSPOOL SEEPAGE PIT OTHER <br /> I <br /> REPAIRS: TYPE OF REPAIRS; <br /> vi . <br /> . v0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: f�• ;gat C ?ani . <br /> t -C <br /> A <br /> i <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> _ <br /> I - <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> h ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE tOF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> E SIGNED: CONTRACTOR: ' <br /> FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED BY DATE: L <br /> ADDITIONAL COMMENTS: <br /> PHASE III/FINAL <br /> PHASE II <br /> i INSPECTION BY: DATE t)- - INSPECTION BY- DATE <br /> E H 1426 '.-SAN'--JOAQUIN LOCAL HEALTH DISTRI v 1/72 1M <br /> E DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />