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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 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 /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTHDISTRICT. J <br /> 1:2 r 6 <br /> JOB ADDRESS/LOCATION: F CENSUS TRACT: 6-1 <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: 1 LICENSE PHONE: <br /> .INTENDED USE: INDIVIDUAL .DOMESTIC WATER"WELL X/ PUBLIC WATER WELL /% TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / J INDUSTRIAL WATER WELL <br /> CATHODIC -PROTECTION WELL J / GEOPHYSICAL WELL / / OTHER /_7 <br /> y <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYr!- <br /> SEWAGE DISP05AL FIELD �OQ CESSPOOL SEEPAGE PIT •— OTHER <br /> REPAIRS: TYPE OF REPAIRS: i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> �t <br /> PLOT PLAN: ' SHOW ON REVERSE SIDE <br /> - <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE 'DONE IN <br /> ACCORDANCE THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNT OF SAN JO QUIN, AND TH lES:�7ATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: f DATE: .& � <br /> ADDITIONAL COMMENTS: <br /> PHASE II P S II FINAL <br /> INSPECTION -BY: ' DATEINSPECTIO . B DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT I/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER —PINK-CONTRACTOR <br />