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FO "J pE=.WELLR"pUMI' PLItlII1. _ ... <br /> (Complete in Triplicate) PERMIT NO. <br /> Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L <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 /> SIO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> TOB ADDRESS/LOCA ON: _/� <br />•)WNER'S NAME: . CENSUS TRACT: _/ <br />.DDRESS: PHONE: <br />:ONTRACTOR'S NAME: CITY: <br /> LICENSE # PHONE: - <br /> NTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /- _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / IND USTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER %% <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SSEEEPAGE PIT OTHER <br />?PAIRS: TYPE OF REPAIRS: <br /> s <br /> .ANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> � C I <br /> F ' <br /> 5 ' <br />-0T PLAN: SHOW ON REVERSE SIDE <br />-HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> -ORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> JNTY OF S JOAQU N, An THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> ,'NED: �/ CONTRACTOR: 1 <br /> FOR DEPARTMENT USE ONLY <br /> E t <br /> I,ICATION ACCEPTED BY: �� _ DATE: � � "� <br /> ITIONAL COMMENTS : <br /> _ t <br /> --- PHASE II PHASE I.II/P_L_NAL - <br /> PECTION BY:-LI& _ DATE 3-'�7 INSPECTION BY : T—KO_-__ DATE <br /> 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> TRIBLITION : WHITH 11EAi,TII DI TRICT - YELLOW-PROPERTY OWNER - PINK-C01.71RACTOR <br />