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C f <br /> FOR OFFICE USE: APPLICATI FOR WELL OR PUMP PERMIT PERMIT N0. -L <br /> (Complete in Triplicate) Date Issued: c4.17-7 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: CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: G n CITY: S <br /> CONTRACTOR'S NAME: p x LICENSE �rPHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /—INDUSTRIAL WATER WELL <br /> CATkODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 7,!�~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 /> 5 <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 HP.ALTH. DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: Y- DATE: %^ -_7 <br /> ADDITIONAL COMMENTS: <br /> PITA E P I FINAL <br /> INSPECTION BY• DATE – l/� INSPECTION BY:O-COYI <br /> TE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DIS 172 1M <br /> DISTRIBUTION IT -HEALTH DISTRICT -- YELLOW-PROPERTY OWNER <br />