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FOR QFFICE USE: APPLICATION FOR WELL OR PUMPPERMIT PERMIT NO. 1 2�- <br /> Date Issued: ! <br /> - ('Complete in Triplicate) l ZJJ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREB E 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 />` p <br /> JOB ADDRESS/LOCATION: �3 CENSUS TRACT:PHONE: �? <br /> OWNER'S NAME: <br /> CITY: Ag <br /> ADDRESS: t LICENSE 4d PHONE: - <br /> CONTRACTOR S NAME: <br /> INTENDED USE: TNDIVI UAL DOMESTIC TER WELL & PUBLIC WATER WELL / / TEST WELL /� <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL /� <br /> CATHODIC PROTECTION WELL / I GEOPHYSICAL WELL / I OTHER I I <br /> - I <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK(} SEWER LINES& PPIT PRIVY W f3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> d <br /> REPAIRS: TYPE OF REPAIRS: <br /> . 1 <br /> 1 p <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> C-1 <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 JOA IN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> r <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: _ - — DATE: 2 e---�� <br /> ADDITIONAL COMMENTS: <br /> I PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 .;1M <br /> E H 1425 _ - - <br /> OWNER - PINK-CONTRACTOR <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY <br />