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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -Z oz) <br /> (Complete in Triplicate) Date Issued: 41/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `- <br /> f <br /> I " <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> LIC <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 N: 78 C, CENSUS TRACT: IQ <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: O CITY: <br /> CONTRACTOR'S NAME: LICENSE # �fPHONE: ��, <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /0 PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL/% OTHER / / ; <br /> 'I <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES _5C2/PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> I <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> h <br /> • `r <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 ' OAQUIN, AND THE ULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> f <br /> } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g p <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE (! -�f �,� INSPECTION BY: DATE <br /> E H 1426 �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR G <br />