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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO <br /> (Complete in Triplicate) Date Issued: <br /> T IS 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 /> .TOB ADDRESS/LOCATION: 4. ��� S o-- Y�d, CENSUS TRACT: <br /> OWNER'S NAME: �,!j_ y 6 k PHONE: <br /> CM, CITY: 1✓121� c_r� <br /> T ZL <br /> R NAME: 1 . T--e-J,/ LICENSE # PHONE: ' g_ <br /> IRT&6ED UQ INDIVIDUAL DOMESTIC WATER WELL /PUBLIC WATER WELL / / TEST WELL /_7 <br /> z LA IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> C" ,.i ti 0 CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /% OTHER /_7 <br /> o � <br /> N� WELL: 3;I§TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS. TYPE OF REPAIRS,. <br /> lVe �,/ 1 h.1� s <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 t <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: v DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE �/ - 2-1;'- 7L <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />