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r <br /> FOR OFF I E USE: APPLICATION FOR WELL OR Pali PERMIT PERMIT NO. L -3� ' <br /> (Complete in Triplicate) Date Issued: 7- <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 17 <br /> OCAL HEALTH DISTRICT. <br /> 708 ADDRESS/LOCA ION: 6'$" p CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: ,(� CITY: <br /> CONTRACTOR'S NAME! 00 As ea•vS . LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL %J <br /> CATHEl-PROTECTION WELL J GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK A / SEWER LINES/w/ PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD/So/ CESSPOOL SEEPAGE PIT /ap/ OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> j <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 <br /> � PHASE III/FINAL <br /> INSPECTION BY: DAT � �I`N"SPECTION BY: 21� DATE 6 �Z <br /> E H 1426 SAN JOAQUIN-LOCAL_HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />