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r APPLICATION FOR WELL OR PUMP 'PERMIT PERMIT NO. <br /> FOR OFFICE USE: ( <br /> Date Issued: <br /> .r Complete in Ttciplicate) <br /> T'HI , PERMIT EXPIRES I 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 COMPIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOC LTH DISTRICT. <br /> JOB ADDRESS/LOCAT ON: CENSUS TRACT: <br /> D 3 <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: �// CITY: <br /> CONTRACTOR'S NAME: LICENSE _____�r PHONE: _ ? <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL <br /> PUBLIC WATER WELL / / TEST WELL / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f / GEOPHYSICAL WELL / / OTHER I / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK/&V" SEWER LINES //a r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD //W1 CESSPQOL SEEPAGE PIT/6Q OTHER <br /> REPAIRS: TYPE OF REPAIRS: J <br /> V'1 <br /> sz <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ` � DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIZ FINAL <br /> INSPECTION BY° DATE _ INSPECTION BY: DATE S 2 �— <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT -- YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />