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F y F <br /> tai: <br /> FOR OFFICE=USB: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z �I D'E_ <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> P <br /> APPLICATION- IS HEREBY DE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM i <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/LOCA ON: kt;_8%6 d CENSUS TRACT: SSI <br /> OWNER'S NAME: PHONE: 36 ao2� <br /> ADDRESS: S ahj CITY: <br /> CONTRACTOR'S NAME: LI EN A� PHONE: � <br /> -V C3� . <br /> INTENDED USE: INDIVIDUAL .DOMESTT WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSIbAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - I <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: O ; <br /> of <br /> A1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> t <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: - CONTRACTORS <br /> FOR DEPARTMENT USE ONLY E <br /> PHASE I <br /> 4DATE: <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIT/FINAL <br /> INSPECTION BY: TATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT �' f 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK -CONTRACTOR [ ,, <br />