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FOR OFFICE USE: APP/LICATION FOR WELL OR PUMP PERMIT PERMIT NO, <br /> (Complete in Triplicate) ZZ• z-�3 <br /> IS PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: N e vi c if <br /> OWNER'S NAME: 1&4 NSUS TRACT <br /> ADDRESS: PHONE: r <br /> Fe. CITY: w <br /> CONTRACTOR'S NAME: ­7,,�_. ,S-. LICENSES PHONE: s <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /7 TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL J// <br /> CATHODIC PROTECTION WELL El- GEOPHYSICAL WELL L/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS:. TYPE OF REPAIRS: T ? r <br /> t.� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> p <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 z FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASEIII FINAL <br /> ��jj r <br /> INSPECTION BY: _ DATE INSPECTION BY: i 0�•(� DATE -fZ-.� <br /> H 1425 SAN JOA UIN LOCAL HEALTH DISTRICT 1J72 <br /> IM <br /> rISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK--CONTRACTOR <br />