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FOR-OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued:%z=Z z_,7a <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 LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �J�S /��� `✓q/ CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: G Lb CITY: <br /> CONTRACTOR/'S NAME: LICENSE 41.2oCPZ5WHONE: <br /> aw- <br /> INTENDED USE: INDIVIDUAL D6MESTIC WATER WELL / / PUBLIC WATER WELL IK TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / %INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / 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 />{ <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 PROVTTH <br /> OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOA AND RE LATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: �f <br /> [ FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> ,APPLICATION ACCEPTED BY: DATE:' <br /> 00, <br /> ADDITIONAL COMMENTS: EZZ <br /> PHASE II <br /> FINAL <br />( INSPECTION BY: v btLLDATE. INSPECTION BY: DATE <br /> EE H 1426 SAN' JOA UIN LOCAL HEALTH DISTRICT 1/T2 �. <br /> DISTRIBUTION: . WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK- 0 CT¢R lip <br />