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FOROOFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. �-5 (" / <br /> (Complete in Triplicate) Date Issued: �3' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED q y s 7 <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 JOAQUILOCAL -HEALTH DISTRICT, <br /> .TOB ADDRESS/LOCATIO ads S ?-",(-`7- 0 <br /> CENSUS TRACT: ��- <br /> OWNER'S NAME: PHONE: <br /> 7-7 <br /> ADDRESS: !� CITY• <br /> CONTRACTOR'S NAME: /� L. <br /> LICENSE # �- ` L� Q PHONE: 17,�Gr <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL f 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 S�C� SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER w <br /> e <br /> llG�� <br /> V3 <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: -.METHOD TO BE USED: j <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- LAtlWS OF--THE STATE OF CALIFORNIA,, THE�ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY4 i y <br /> PHASE I <br /> ,f <br /> APPLICATION ACCEPTED BY: <br /> DATE: <br /> ADDITIONAI, COMMENTS: <br /> __22f t <br /> CL_ <br /> C/ <br /> PHASE II PHASE,III/?'I_NAL <br /> INSPECTION BY: Z__BATE .� INSPECTION BY:_t4 DATEJ/- 1- 72--. <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 <br /> im <br /> DISTRIBUTION: WHITE-HEALTH, DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />