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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: 1.7_1.7 <br /> T IS 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 ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: 1 -19 i QQ 4 o _� P j t PN_UI LIg1I�� L GCENSUS TRACT <br /> OWNER'S NAME: Pk PHONE: <br /> ADDRESS: 174it, C, CITY: <br /> CONTRACTOR'S NAME: 5L F -_ __ - LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL ,DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTU L WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> t <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT - OTHER <br /> REPAIRS: TYPE OF REPAIRS: =ALL _ N0- fy1_P-- - -dr L2 E�1 1 W r= !.= - <br /> T, <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r � <br /> 5 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILLBEDO E 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: /!!/Lo <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: 4 DATE -3 _ 'Z <br /> --: <br /> ADDITIONAL COMMENTS: <br /> r <br /> PHASE II PHASE III/FINAL <br /> f <br /> INSPECTION BY: DATE INSPECTION BY: 40 ' DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTR_IC_T 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />