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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMITa ' <br /> iM (Complete' in Triplicate) <br /> PERMIT N0. 7�- <br /> �M IS PERMIT EXPIRES lYEAR FROM DATE ISSUED Date Issued: <br /> APPLICATION ISMEREBY 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/LOCAT <br /> OWNER'S NAME: CENSUS TRACT: <br /> ADDRESS: PHONE: <br /> CONTRACTOR'SAME; CITY: <br /> ` LICENSE # PHONE: + <br /> INTENDED USE: �i VIDUAL DOMESTIC <br /> .F. WATER WELL / PUBLIC WATER WELL / / TEST WELL /_ i <br /> IRRIGATION/LIVESTOCK/AGRICUL L WATER WELL INDUSTRIAL WATER WELL <br /> / <br /> CATHODIC PROTECTION WELL / LL/ GEOPHYSICAL WE / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER , <br /> I <br /> REPAIRS: TYPE OF REPAIRS: <br /> 71- <br /> U� <br /> J <br /> 4 <br /> II r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: W <br /> L <br /> �I i <br /> PLOT PLAN: SHOW ON REVERSE SIDE i <br /> I <br /> I HEREBY CERTIFYjTHAT I HAVE PREPARED THIS APPLICATION AND T <br /> HAT 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 J0 U AND TH LES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> SIGNED: Il ` . � <br /> CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY:� d y � � <br /> kDDITIONAL COMMENTS; DATE: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: <br /> DATE INSPECTION BY: DATE <br /> H 1426 SAN JOAQUIN LOCAL HEALTH DISTRIG <br /> PI_�,__ <br /> ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR 1/72 1M <br />