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FOR OFFICE USE: A��ICATION FOR WELL" OR PUMP T'E'RM PERMIT NO. <br /> I*_. ` (Complete in Triplicate) Date Issued: -Z--Iq-7 <br /> T\R1TRI 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 ORD 0 <br /> N0. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUTN IAC LTH DYSTRICT, r <br /> �� <br /> F <br /> JOB ADDRESS/LOCAT ON: J. � CENSUS TRACT:' <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 1 / CITY: <br /> CONTRACTOR'S NAME: b LICENSE # 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 WELL %% OTHER . { <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK AtO/ SEWER LINES //a 0'PIT PRIVY <br /> SEWAGE DISPOSAL FIELD f/gWI CESSPOOL SEEPAGE PIT/�O flT <br /> x <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USEDo r <br /> PIAT PLAN: SHOW ON REVERSE SIDE <br /> M. <br /> I 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 r7 <br /> APPLICATION ACCEPTED BY: (� ` �. __ _ DATE: <br /> ADDITIONAL COMMENTS: <br /> � PHA , PHASE III FINAL <br /> INSPECTION BY�. DATE _ INSPECTION BY: DATE 3 2�� <br /> + E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT x/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER -- PINK-CONTRACTOR <br />