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4 FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: <br /> "r HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> t x <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEA <br /> LTH DISTRfCT THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH FCOUNTY ORDOR AI NANCEERFORM <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> JOB ADDRESS/LOCA ON: <br /> OWNER'S NAME: CENSUS TRACT: <br /> ADDRESS: PHONE,Y/f� - b <br /> CONTRACTOR'S NAME: CITY: <br /> LICENSE # PHONE: �f / <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /- /_r PUBLIC WATER WELL 2 TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTUTRAL'WATER WELL- - INDUSTRIAL:-WATER=WELL-%/_;" <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 14ra SEWER LINES .PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPO L SEEPAGE PIT OTHER `aL t'104. TA a S e <br /> k - <br /> REPAIRS: TYPE OF REPAIRS: cJ�j <br /> +_j <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ay <br /> IP <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 k <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 <br /> CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: AT <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FI AL <br /> f <br /> INSPECTION BY: .� DATE I r/'Y INSPECTION BY: DATE p2 <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRI <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR I/72 7M <br />