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POR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. p ,� <br /> (Complete in Triplicate) Date Issued: j1.7i/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE 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: CENSUS TRACT: <br /> OWNER'S NAME: �,�•�_r 7. .r'., ., ,,, , PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: r .. ► . LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL LSI PUBLIC WATER WELL /7 TEST WELL L7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL L7 <br /> :ATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L_7 OTHER 1_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: f -! <br /> 1 <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: r �"?rr :►�, <br /> OR DEPARTMENT USE ON Y <br /> PHASE I `� —7 <br /> APPLICATION ACCEPTS DATE: — ( <br /> ADDITIONAL COMMENTS: <br /> 6v <br /> PHASE II owl PHASE III FINAL <br /> ;Vol- <br /> INSPECTION BY: DATE INSPECTION BY: - <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT .1/72 1M a,k <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER PM—CONTRACTOR '__ 71 <br />