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FOF OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. ' Z- <br /> (Complete in Triplicate) Date Issued: Z_ ?� <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 DISTR T. <br /> JOB ADDRESS/LOCATION: w E CENSUS TRACT: O(off--5-1,0 -4 / <br /> OWNER'S NAME: PHONE: 4 9-!P 3 S� <br /> ADDRESS: Y' CITY: X <br /> CONTRACTOR'S NAME: _ .D --.._. LICENSE # PHONE: _ 2 <br /> INTENDED USE: IND IVI AL :DOMESTIC WATER WELL / / PU�IC ' / LL / / TEST WELLIRRIGATI LIVESTOCK/AGRICULTURAL WATELL /INDUSTRIAL WATER WELLCATHODIC PR TION WELL / / GEOPHYSIW / OTHER I I <br /> # ------- <br /> t NEW WELL: DISTANCE TON ST: SEPTIC TANK \rxEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. LD CESSPOOL SEEPA PIT OTHER <br /> r <br /> REPAIRS: TYPE OF REPAIRS: 12 Ah. - . <br /> f� <br /> c ABANDONMENT/DESTRUCTION: - METHOD TOT BE USED: <br /> fZ <br /> PLOT PLAN: SHOW ON REVERSEfSIDE <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 THEEI RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: 10 <br /> ` CONTRACTOR: <br /> FORDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: � /� DATE: 21 <br /> ADDITIONAL COMMENTS: <br /> PHASE- II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: i�� ZZDATE <br /> F H 1426 "—SAN-JOAQUIN LOCAL HEALTH_DISTRICT 1/72 1M <br /> 'STRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />