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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED - <br /> _ <br /> APPLICATION IS HEREBY DE 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. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: <br /> OWNER'S NAME: � d G 12,!i PHONE: $_35-77073 <br /> ADDRESS: IS O RIVE CITY: <br /> CONTRACTOR'S NAME: �r o- LICENSE # PHONE: $'3%_,;2 p 7 - <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL P TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER s <br /> REPAIRS: TYPE OF REPAIRS: A n 01 a Cd,Cy m - 7/, P � u a <br /> • ABANDONMENT/DESTRUCTION: METHOD TO� BE USED: <br /> i <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: 70 <br /> t <br /> w FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: / -C r. r_ "/ ��� ___ _ DATE: <br /> .ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: N' s DATE <br /> E H 1426 . SAN JOAQUIN 'LOCAL HEALTH_DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />