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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT <br /> PERMIT N0. <br /> (Complete in Triplicate) Date Issued• <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED zd 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 JOAQUIN LOCAL HEALTH DISTRICT, <br /> I S 8'��.✓.• o Lf 1-11-7-o <br /> JOB ADDRESS/LOCATION: LOT 25 <br /> CENSUS TRACT: <br /> OWNER'S NAME: ore �BEALTY TA a nT <br /> ADDRESS: PHONE: _ <br /> CONTRACTOR'S NAME. It,kii CITY: <br /> LICENSE # PHON <br /> INTENDID}U.SE: INDIVIDUAL DOMESTIC WATER WELL-/X/ PUBLIC WATER WELL-/77/. -TEST -WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_/ INDIfSTRIAL WATER WELD, / <br /> "ATHODIC PRDTECTION WELL,_ /• ,gEOPHYSICAL WELL / / OTHER <br /> s <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: Determine if existing weld, is usable, � <br /> ABANDONMENT/DESTRUCTION: METHOD__TO BE USED: w <br /> kzs <br /> PLOT PLAN: SHOW ON'REVERSE SIDE A <br /> f <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: <br /> CONTRACTOR- <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: P - DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II "` [[ PHASE TII/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: _ DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR y� <br />