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a APPLICATION- FOR WELL OR PUMA" PERMIT PERMIT NO. `� � <br /> FOR OFFICE DSE: Issued: <br /> (Complete in Triplicate) Date �- <br /> HIS 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 /> JOB ADDRESS/LOCATION: �� I al �`GTION V/= CENSUS TRACT: G <br /> 77 <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> NAME: 1�6I ,ICENSE # ?�B�oa_ PHONE: <br /> CONTRACTORS _G /� �� <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL //—INDUSTRIAL INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK t.6r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `'CESSPOOL SEEPAGE PIT OTHER <br /> W <br /> REPAIRS: TYPE OF REPAIRS: -� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> fy .YLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> 1 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 /> k t <br /> SIGNED: CONTRACTOR: 624&—a4ez <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I d <br /> APPLICATION ACCEPTED BY: DATE: <br /> f ADDITIONAL COMMENTS: <br /> PHASE II <br /> PHASE III/FINAL <br /> INSPECTION BY: S" -�a- DATE �1u�'" INSPECTION BY: -� DATE --- � <br /> kE H 1426 JOA UIN LOCAL HEALTH DISTRICT <br /> /72 1PI <br /> : DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />