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F I <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. L 5 I <br /> (Complete in Triplicate) Date Issued: Z <br /> 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 i <br /> z <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. Y <br /> 17:47M <br /> -C; <br /> JOB ADDRESS/LOCATION!'r 'L.CENSUS TRACT: i <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: / CITY: <br /> CONTRACTOR'S NAME: LICENSE 1���, 373 PHONE: -- _3 r, <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /7 1 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: �EPTIC TANKR -LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAG IT OTHER <br /> REPAIRS* TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 11 V <br /> PLOT PLAN: SHOW ON REVtRSE„SIDE # <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> LLACCORDANCE 'WITH THE PROVISIONS OF THE—LAWS OF THE STATE'OF CALIFORN14"THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND /THE RULES AND REGULATIONS OF THE SAN JOAQU(IN 'LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: SCJ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: [� 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: • DATE (0 "' A`Ict <br /> E H 1426~� - SAN' JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />