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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in TrDate Issued: - I74z ; <br /> T IS PERMIT EXPIRES l 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 JO UI OCAL HEALTH DISTRICT. j <br /> JOB ADDRESS/LOCAT O C tJ Lv ENSUS TRACT: S4/ 1 <br /> OWNER'S NAME• PHONE: 36e's-, y:H <br /> ADDRESS: ^a CITY: <br /> CONTRACTOR S NAME: _ LICENS"4 PHONE: 6 0 <br /> INTENDED USE: INDIVIDUAL DOMESTIC ER WELL PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /—INDUS—TRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br />- �. -��w'Y N �swrwJmla: . .fele-' f,�- • i <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANKY SEWER LINES PIT,,PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGEJPIT .OTHER`,:' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO_BE USED: <br /> i <br /> r <br /> rPLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY`"CERTIFY-THAT-1 HAVE-PREPARED`-THIS'APPUICATION AND^THAT-THE'WORK-WILL­�BE-DONE-I-N— <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: <br /> e <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: � a <br /> ADDITIONAL COMMENTS: <br /> i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATEt. <br /> f E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> k - <br />