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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT <br /> PERMIT N0. <br /> (Complete in Triplicate) Date Issued: <br /> THIS 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 ADDRESS/LOCATION: 3 M� + S 7 <br /> OWNER'S NAME: CENSUS TRACT: <br /> ADDRESS: PHONE: <br /> CONTRACTOR'S NAME: LICENSE Tf �f p PHONE: 2 2 ro. y <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 /> REPAIRS: TYPE OF REPAIRS: <br /> ---------------- <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 JO QUIN, AND THPIRULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 4 <br /> SIGNED: r CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINALpp <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR n <br />