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FOR OFFICE USE: (APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO.(Complete in Triplicate) Date Issued: 5 1-5 7PERMIT EXPIRES 1 YEAR FROM DATE ISSUED q V 7 Y) <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 /> SOB ADDRESS/LOCATION• 3 Z Gr.�,$ CENSUS TRACT: <br /> OWNER'S NAME: PHONE: ,-- U <br /> ADDRESS: p CITY: <br /> CONTRACTOR' NAME: LICENSE 4i .2al,C2� PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /_/ GEOPHYSICAL WELT'/ / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER Z, <br /> REPAIRS: TYPE OF REPAIRS: <br /> tl <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: Yt, <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORD 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 T RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEAL DISTRICT. <br /> n � <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: .Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL Iry <br /> INSPECTION BY: DATE INSPECTION BY: DATE 7--/0'7.�y <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />