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P <br /> FOR OFFICE USE: APPLICATION FOR WELL OR UMP PERMIT V PERMIT NO. ]L-17 <br /> (Complete in Triplicate) Date Issued: _3 .Z z- Z <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' i <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: �? i CENSUS TRACT: <br /> OWNER'S NAME: ok <br /> P <br /> ADDRESS: COr� � <br /> ITY:a <br /> LICENSE PHONE: 44 <br /> � p�$ <br /> CONTRACTOR'S NAME: �� -` <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER ,TELL PUBLIC WATER WELL /TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /—INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> " NEW'WELL:'DISTANCE TO NEAREST:~ SE IC TANK SEWS PI VY <br /> SEWAGE DIS FIELD OL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: jj, - <br /> L <br /> L ! � _ <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> f <br /> t <br /> 1 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> 1 <br /> rI-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 DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: C DATE: �. <br /> ADDITIONAL COMMENTS: <br /> � 1 <br /> PHASE II I PHASE III FINAL <br /> 1 INSPECTION BY: DATE <br /> INSPECTION BY: / % DATE - <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 :M <br /> i DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />