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A <br />FOR OFFICE USE: l KATION FOR WELL OR PUMP PERM PERMIT NO. <br />Z <br />(Complete in Triplicate) Date Issued: •�--� '7 z <br />THIS 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: <br />OWNER'S NAME: <br />ADDRESS: �__ <br />CONTRACTOR'S NAME: � <br />TRACT: <br />PHONE: <br />CITY: <br />PHONE: <br />INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /_/ PUBLIC WATER WELL / / TEST WELL /% <br />IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSTRIAL WATER WELL /_ / <br />CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER /_7 <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: <br />ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 CONTRACTOR: <br />FOR DEPARTMENT USE ONLY <br />PHkSE I <br />APPLICATION ACCEPTED BY :,�,�� DATE: <br />ADDITIONAL COMMENTS: <br />PHASE <br />� I PHASE III/FINAL <br />INSPECTION BY: /y DATE INSPECTION BY: ` ,� DATEZ—'" <br />E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br />DISTRIBUTION: WHITE -HEALTH DISTRICT - YELLOW -PROPERTY OWNER - PINK -CONTRACTOR <br />