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FOR OFFICE USE': AP LICATION FOR WELL OR PUMP PERMIT PERMIT N0. _ t 3 <br /> (Complete in Triplicate) Date Issued: <br /> T IS 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 /> ° `` Tri� r w <br /> /LOCATION: �.S' � •'- �� a � <br /> OWNER'S NAME: " S CENSUS TRACT: <br /> 11ADDRESS: <br /> PHONE: <br /> CONTRACTOR'S NAME: LICENSE #2,2-4_g 0 gHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELLf PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSTRIAL WATER ^' <br /> CATHODIC PROTECTION WELL El- GEOPHYSICAL WELL / / OTHER WELL <br /> ' f <br /> I <br /> NEW WELL: DISTANCE TO NEAREST: S PTIC TANK <br /> SDSEWER LINES, PIT PRIVY OLI(JYit <br /> SEWAGE DISPOSAL FIELD AJ0*CESSP00L SEEPAGE PIT/QQ OT"HER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I ,y <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT T 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 OAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEAL H DISTRICT. <br /> SIGNED: CONTRACTOR: Ov, <br /> PHASE I FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY: y6A'�lDATE: <br /> ADDITIONAL COMMENTS; <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN' JOA UIN LOCAL HEALTH"DISTRICT_ ' 1/77 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />