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\ r <br /> FOR OFFICE USE: \r APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0, y <br /> (Complete in Triplicate) Date Issued _ y <br /> THIS 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: CENSUS TRACT: Ort <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: D CITY: _ <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /% PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRTAL WATER WELL /_7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL //_/ OTHER <br /> { <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 /> W <br /> O <br /> ABANDONMENT/DESTRUCT: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> St <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 4.. <br /> 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: - <br /> CONTRACTOR: � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIflN ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIi FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE ZZ <br /> E H 1426 SAN JOAQUIN LOCAL_ HEALTH DISTRICT 1172 1M # <br /> DISTRIBUTION: WHITE•-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> i <br />