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a <br /> f <br /> FOR-OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: L <br /> TH ,S PERMIT EXPIRES I 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 <br /> ISTRICT.JOB ADDRESS/LOCA ON: CENSUS TRACT: <br /> OWNER'S NAME: zA A&APHONE: <br /> ADDRESS: CITY: r �. <br /> CONTRACTOR'S NAME: LICENSE # 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 /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> a <br /> REPAIRS: TYPE OF REPAIRS: Yjkl <br /> r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ., <br /> �I <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> ll' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN _I <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE I <br /> COUNTY OF 3bAQU , THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: r DATE: <br /> ADDITIONAL COMMENTS: <br /> { <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: { DATE _3''24--_7� INSPECTION BY: L1- DATE -72L- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY -OWNER - PINK-CONTRACTOR 1 <br />