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6 <br /> FOR OFVICE.-,0SE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> z-1- -:376 <br /> (Complete in Triplicate) Date Issued: z <br /> THIS PERMIT EXPIRES I YEAR FROM BATE 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/LOCATIO CENSUS TRACT: OO <br /> OWNER'S NAME; <br /> ADDRESS: <br /> PHONE:_ <br /> CITY. <br /> CONTRACTOR'S N )ICENSE # (PHONE: —« <br /> INTENDED USE: INDIVIDUAL .DOMES IC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL,WATER WELL /-7 INDUSTRIAL WATER WELL /% <br /> CATHODIC PROTECTION WELL j/1- GEOPHYSICAL WELL L_1 OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 16JP SEWER LINES 490"PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD /G0/ CESSPOOL SEEPAGE PIT/,f9 OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED; <br /> F r <br /> Y <br /> 1 <br /> ,I <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: <br /> 1 <br /> FOR DEPARTMENT U <br /> PHASE I USE ONLY <br /> s <br /> APPLICATION ACCEPTED BY: DATE: -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE <br /> INSPECTION BY; DATE 2— I <br /> E H 1426 JEAN JOAQUIN LOCAL HEALTH DISTRICT 1/7.2 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> i <br />