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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -Z' 0 <br /> (Complete in Triplicate) Date Issued:X �� <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THESANJOAQUIN 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 /> ,, ti <br /> JOB ADDRESS/LOCATION:"S'; S n /� )„ YCENSUS TRACT: <br /> OWNER'S NAME: d" PHONE: f. 2- <br /> ADDRESS: � �' ' CITY: ° <br /> CONTRACTOR'S NAME: ----! LICENSE # 7 PHONE: <br /> INTENDED USE: .INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ IND6—STRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f-1 GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> M � <br /> �f <br /> 4 1 <br /> ABANDONMENT/DESTRUCTION�' .METHOD TO BE USED: <br /> Of <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 DISTRIC <br /> SIGNED: -- - CONTRACTOR:• -- <br /> ._- <br /> FOR DEPARTMENT ,USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II -OSE SE II/FINAL <br /> F , <br /> INSPECTION BY: DATE INSPECTION BY: 4 <br /> DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER -- PINK—CONTRACTOR <br />