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Teo <br />FOR OFFICE'U SE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT`NDss:"; = ° <br />(Complete in Triplicate). Date Issued': <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />APPLICATION ISRBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIX_ -O-PERFORM <br />I THE WORK STATED EREEON.' THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDI <br />! NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT.,: <br />JOB ADDRESS/LOCATION: _ `CENSUS TRACT: 4 <br />OWNER'S NAME: I PHONE:,= / <br />ADDRESS / ► / ' CITY: E` -� f <br />j CONTRACTOR'S NAME: --77 ]], r -rr h/ d� s� ,e A10 LICENSE # PHONE: _ � _ a ae, y <br />INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /prPUBLIC WATER WELL /_/ TEST WELL /-% _.__ <br />IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /'/INDUSTRIAL WATER WELL <br />CATHODIC PROTECTION WELL / LL / GEOPHYSICAL WE /_ / 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: ru/I -k' , 'Ili d d -_-_fl, _Pg -_ zy.61 IL _' <br />ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br />PLOT PLAN: SHOW ON REVERSE SIDE <br />T <br />i - <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 />4 <br />E SIGNED: `,,� i,i;� CONTRACTOR: <br />FOR DEPARTMykg USE ONLY <br />PHASE I �1 <br />APPLICATION ACCEPTED BY: <br />ADDITIONAL COMMENTS: <br />DATE: Lam111 %-1- <br />PHASE 1I f PHASE III FINAL <br />INSPECTION BY: DATE _ INSPECTION BY: _Cii DATE - Z Z - <br />E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 <br />DISTRIBUTION: WHITE -HEALTH DISTRICT -- YELLOW -PROPERTY OWNER - PINK -CONTRACTOR <br />