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FOR OFFICE USE: APPLICATION FOR"WELL OR,.PUMP PERMIT PERMIT NO. '��- Z a ' <br /> (Complete_-in, Triplicate) Date Issued: <br /> XH S PERMIT EXPIRES `l YEAR FROM'DATE ISSUED <br /> APPLICATION IS HEREBY MADE T0''THE`SAN'iJOAQUIN LOCAL' HEALTH `DISTRICT FOR -A'PERMIT TO ,PERFORM <br /> THE WORK STATED HEREON.- �THI5{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 i.' t. © ""' CENSUS TRACT; ' <br /> OWNER'S NAME: Jq P�, C,.�Q � c A c,_ M D. PHONE: <br /> ADDRESS: ,, ,. _ -- <br /> _� CITY: [' ce✓ <br /> CONTRACTOR'S NAME:' - LICENSE # <br /> PHONE": �a6'7 <br /> INTENDED USE: INDIVIDUAL..DOMESTIC WATER; WELL J_'PUBLIC WATER WELL / / TEST ,WEL-L •/• / _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / J OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: p z �ic T )�✓;.,A <br /> } <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: m <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 /> i, <br /> SIGNED: 7 CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> .APPLICATION ACCEPTED BY: � rJ_ DATE: � �/ ,'2- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHASE II it PHASE III FINAL <br /> 9 <br /> INSPECTION BY: DATE INSPECTION BY: DATE - <br />.ErHy1426 ­'"SAN--JOAgUIN"LOCAL HEALTH DISTRICT 1/72' 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />