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FOR OFFICE USE: APPLICATION FOR WELL OR PuMp PERMIT <br /> (Complete in Triplicate.) PERMIT N0. ) �-1 t' <br /> y Date Issued: � <br /> THIS PERMIT E%FIRES 1 YEAR FROM DATE ISSUED ' <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCEERFORM <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: <br /> t OWNER'S NAME: L L L a CENSUS TRACT: s y <br /> ADDRESS: L PHONE: <br /> CONTRACTOR'S NAME: L" CITY: - <br /> LICENSE # L&&SM0_& PHONE: _ D <br /> INTENDED USE: INDIVIDUAL.I?OMESTZC WATER WELL / <br /> PUBIRRIGATION/LIVESTOCK/AGRICULTURAL WATERLWELLATER WELL / / TEST WELL /-7 _ <br /> �- ATRODIC PROTECTION WELL. // INDUSTRIAL WATER WELL <br /> /,_GEOPHYSICAL WELL E/ OTHER % <br /> rr.►. ,�, - ..�,�.owftw* ' .�y <br /> I ► <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK D,* SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS. <br /> LL VV Ll1 L� i . <br /> v � -A <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED- m <br /> i , <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANDTHATTHE WORK WILL BE DONE IN f <br /> ACCORDANCE WITH THE PROVISIONS :OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY dF SAN JO QU , AND THE RULES AND REGULATIONS OF THE SAN JOA UIN LOCAL <br /> { /� Q HEALTH DISTRICT. <br /> SIGNED: ' <br /> CONTRACTOR: & S < <br /> PARTMENT USE ONLY <br /> PHASE I FOR DEI <br /> kPPLICATION ACCEPTED BY: <br /> kDD.ITIONAL COMMENTS: <br /> PRASE II ' <br /> ��`� v ' PHASE III FINAL <br /> INSPECTION BY: - + <br /> H,1426 DATE zr. INSPECTION BY: DATE <br /> ISTRIBUTION: WHITE--HEALTH DFSIAICTO- YELLOW-PROP ERTYHOWNER DISTRICT <br /> 1/72 1M <br /> r <br />