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FOR' OFFICE USE: APPLICATION FOR. WELL OR PUMP PERMIT PERMIT N0. 0_3 <br /> Complete„in Triplicate) Date Issued: 3 z 9 7 U 9 <br /> IS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN-4JOAQUIN 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 <br /> ISTRICT.JOB ADDRESS/LOCATION: _ `fill EE= i ” CENSUS TRACT: <br /> r PHONE: _ <br /> OWNER'S NAME: _ <br /> ADDRESS: <br /> CONTRACTOR'S NAME: �Y} 1JJP' CQ LICENSE # s /o3PHONE: - G <br /> INTENDED USE: INDIVIDUAL DOMESTIC- WATER WELL PUBLIC WATER-WELL / / _-TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL VATER WELL / / INDUSTRIAL WATER WELL <br /> CAT DIC PROTECTION WELL / / GEOPHYSICAL WELL LI OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK JQ . SEWER LINES IT PRIVY Wive <br /> SEWAGE DISPOSAL FIELD CZ` CESSPOOL SEEPAGE PIT JAQj:L OTHER <br /> REPAIRS: TYPE OF REPAIRS: ' <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE:USED: v� <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> ��E �'... <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> .ACCORDANCE WITH THE P ISI_ONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOA <br /> ACCORDANCE <br /> RULE REGULATIONS OF THE SAN JOAQUZN LOCAL HEALTH DISTRICT, <br /> E <br /> SIGNED: i Bo / CONTRACTOR: <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I mg: <br /> .APPLICATION ACCEPT f � DATE: Z17 <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II PHASE TTI FINAL <br /> INSPECTION BY:Jfi ©- DATE j' INSPECTION BY: (1 DATE <br /> E H 1426 " SAN-JOA UIN LOCAL HEALTH DISTRICT 1/J2 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />