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FOR OFFICE USE: f APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. - _-- <br /> t {Complete in Triplicate) Date Issued: <br /> -THIS PERMIT EXPIRES I 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 v «ZY CENSUS TRACT: <br /> OWNER'S NAME: rj7P PHONE: ,36 7 3 -/S 3 <br /> ADDRESS: 8 CITY: <br /> CONTRACTOR'S NAME:` CENSE ib5LZy�,S-PHONE: 31!� q_ -yz4641 -d4L' <br /> yd <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL Y/INDUSTRIAL WATER WELL / J <br /> CATHODIC PROTECTION WELL ; / GEOPHYSICAL WELL / / OTHER /% <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 900 ' SEWER LINES `joo " PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT — OTHER — <br /> REPAIRS: TYPE OF REPAIRS: <br /> - <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: -� <br /> . c <br /> 0 <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 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: A J CONTRACTOR: Jf <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: A,?, %�.. , DATE: <- <br /> ADDITIONAL COMMENTS: <br /> PHASE iI PHASE III/FINAL <br /> I <br /> INSPECTION BY: DATE �. <br /> INSPECTION BY: <br /> H 1426 DATE 31 -_/%� - ^',• . <br /> S.�1V JOAQUIN LOCAL HEALTH DISTRICT _ 1/72 1M <br /> )ISTRIBUTION: WHITE--RF,ALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK--CONTRACTOR <br />