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FOR OFFICE USE: APPLICATIONFO WELL <br /> OR PUMP PERMIT PERMIT N0. <br /> s (Complete :Ere Triplicate) <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED bate 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: Q 3,'[ F'j C CENSUS TRACT: <br /> OWNER'S NAME: J^ /"7—C 0--AA Ec _ PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: QQ L4/ ' /- 41 VIP ofOLICENSE # GGG7 PHONE: <br /> �'T�G��TdIY`� <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /_/ PUBLIC WATER WELL j/1_ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_1 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 /> REPAIRS: TYPE OF REPAIRS. a{ <br /> a <br /> 0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: C,172LEN -0 U f <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: CONTRACTOR: <br /> PHASE I ' FOR DEPARTMENT USE ONLY <br /> S <br /> APPLICATION ACCEPTED BY: DATE: -Z_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: _ DATE _ INSPECTION BY: /9 j DATE <br /> s H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br />)ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />