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Is <br /> PERMIT N0. <br /> PLICATION FOR WELL OR PUMA' PERMIT Date Issued: <br /> FOR OF ICE USE: (Complete in Triplicate) 4 <br /> THISPERMIT EXPIRES 1 YEAR FROM DATE ISSUED s <br /> OA UIN LOCAL HEALTH DISTRICT FOR ARMIT TO ORDINANCE APPLICATION IS HEREBY MADE <br /> TO THE SAN J Q CE WITH COUNTY <br /> IS MADE IN <br /> THE WORK STATED HEREON- THIS <br /> TIOI3SIQF THE SAN JOAQUINCOMPLIANLOCAL HEALTH DISTRICT. <br /> NO. 1862 AND RULES AND REGULA <br /> � GEN SUS TRACT: � <br /> _.PHONE: <br /> JOB ADDRESS/LOCATION' I CITY. <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: ! CLICENSE # d a <br /> CONTRACTOR'S NAME: TEST WELL / <br /> 07? PUBLIC WATER WELL / / <br /> WATER WELL / INDUSTRIAL WATER WELL / <br /> i INTENDED USE: INDIVIDUAL.DOPffiSTC TER WELL / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WELL / OTHER <br /> `ATHODIC PROTECTION WELL I/ <br /> WER LINES SPIT PRIVY <br /> DISTANCEST: SE I�QOL SEEPA� ,- -Q-T-HER�� <br /> NEW WELL: SEWAGE DISPOSAL ELD <br /> �l y u <br /> A � Q <br /> REPAIRS' TYPE OF REPAIRS. O <br /> 74 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> P <br /> c <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> f _ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORKTHE ORDINANCES F THE <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, <br /> COUNTY F SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR: <br /> SIGNED: C�3 <br /> FORK/DEPARTMENT USE ONLY <br /> PHASE ]L J DATE, �2 7L.. <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> PHASE III FINAL <br /> PHA E II <br /> INSPECTION BY: gozz�-DATE <br /> INSPECTION BY: DATE 1/72 1M <br /> E H 1426 ..SAN JOA UIN LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR G <br />