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Rr OFFICE USE: APPYIiCATION FOR WELL OR -PUMP PERMIT PERMIT NO. Z (33 <br /> FO - <br /> (Complete in Triplicate) Date Issued: . stir �z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <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 j <br /> NO. 1862 AND. RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. j <br /> I' JOB ADDRESS/LOCATION: - � ., � .&A _-- CENSUS TRACT: I <br /> OWNER'S NAME: A4049a PHONE: <br /> CITY: <br /> ADDRESS: ` <br /> CONTRACTOR'S NAME: "aa LICENSE # 14, PHONE: <br /> E INTENDED USE: INDIVIDUAL DOMESTIC WATER WLL I / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL J / <br /> CATHODIC PROTECTION WELL J J GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE T EAREST: SE C TANK SE NES P IVY <br /> SEWAGE DISPO IELD C LSEEPAGE PIT _OTHER <br /> i <br /> REPAIRS: TYPE OF REPAIRS: 0 <br /> r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: > <br /> t 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 /> w <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: F (`(V�Av�� _ DATE: <br /> ADDITIONAL COMMENTS: s <br /> PHASE II PHASE IIT FINAL <br /> r INSPECTION BY: DATE " INSPECTION BY: DATE <br /> E H 1426 SAN JOA VIN LOCAL HEALTH DISTRICT I/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />