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44 v <br /> FOR OFFICE USR: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> . (Complete in -Triplicate) Date Issued: y <br /> i IS PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> I 1 <br /> APPLICATION IS HEREBYIIMADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREAFTER. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> N0: 1862 AND RULES AND REGULATIONS. <br /> JOB'l ADDRESS/LOCATION:'ill CENSUS TRACT: <br /> ,� i,;+ �/ EitJ E PHONE: 9�Z/ 77.7OWNER'S NAME:. <br /> CITY: , <br /> ADDRESS: <br /> 8 W !M sf � �«acR +6 <br /> 7 <br /> CONTRACTOR'S <br /> LICENSE #� `KIJX,° d� PHONE:4f7 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / // PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/ / / 1 <br /> LIVEST6CK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTIPN WE'LL f / GEOPHYSICAL WELL / / OTHER / <br /> NEW WELL: DISTANCE TO NEAREST. SEPTIC: TANK /00 SEWER LINES ` PIT PRIVY <21 � SEWAGEf��# <br /> DISPOSAL FIELD `' '-CESSPOOL/SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDON/DESTRUCTION: METHOD TO BE USED: v <br /> a <br /> IM d <br /> -t <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> IM j <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH SANI�JOAQUIN CO -ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF THE <br /> SAN JOAQUINfL61C ALT DI TR CT. <br /> SIGNED: y CONTRACTOR: ©� <br /> FORDEP ENT USE ONLY f <br /> PHASE I 7 DATE: / "Z <br /> APPLICATION „,.,;CEPTED BY r -- <br /> ADDITIONAL 1MENTS: ---- <br /> r PHASE I-I PHASE III/FINALDATE 7 <br /> E INSPECTION BY: 1�- DATE t� <br /> SAN JOA UIN LOCAL HEALTH DISTRICT '{ """'� ` V <br /> E,_H G ter. <br />