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FOR OFFICE USE: \ APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. t� <br /> Z?-- 5 <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED q q _-55 <br /> F <br /> APPLICATION IS HEREBY MADE 0 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/LOC ON: J Y> t.Q ( CENSUS TRACT: S`f <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: x'70 . L CITY: ` <br /> CONTRACTOR'S NAME: LICENSE #JG 1_3 7 3 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL 0" PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL -/- LL-/ GEOPHYSICAL WE /_/ OTHER f_7 <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 /> %-A ; <br /> O <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 JOAQUIN, AND 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: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: '� DATE 11 -A 17,E-°- <br /> E H 1426 . SAN JOAQUIN _LOCAL HEALTH DISTRICT 1/72 ].M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />