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FOR OFFICE USE: <br /> APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> 5 Z <br /> (Complete in Triplicate) Date Issued. <br /> HIS PERMIT EXPTRES I 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 /> N0. 1862 AND RULES.AND &EGULAT`IONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, r <br /> .TOB ADDRESS/LOCATION: � 1 <br /> OWNER'S NAME: G CENSUS TRACT: D227--Lffv-1f� <br /> ADDRESS: J PHONE: <br /> CONTRACTOR'S NAME: CITY: <br /> LICENSE # ///�.C4Cs�—PHONE- <br /> .INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL , TEST TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTR 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/IL/ <br /> `oCESSPOOL SEEPAGE PIT OTHER <br /> r ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ' <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: - � <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE - <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br />)ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> r <br />