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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> # (Complete in Triplicate) Date Issued: ? 7 2� <br /> yT IS PERMIT EXPIRES 1 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. 1852 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCAyj0N: , 2J CENSUS TRACT: <br /> OWNER'S NAME: PHONE: ge2. - 2-2 <br /> ADDRESS - ;,� CITY: �;,�� •' <br /> CONTRACTOR'S NAME: LICENSE # 26,5 az PHONE: <br /> INTENDED USE: .INDIVIDUAL DOMESTIC WATER WELL L PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 16-6 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> f <br /> l <br /> REPAIRS: TYPE OF REPAIRS: <br /> 6' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> a <br /> I HEREBY CERTIFY THAT I HAVE -PREPARED THISAPPLICATION 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 AQUIN, AND THE RULES AND•REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> t i k.. <br /> SIGNED: ` CONTRACTOR': <br /> I <br /> FOR DEPARTMENT USK ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �~ DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL; <br /> INSPECTION BY: DATE INSPECTION BY: v DATE L�_��2, <br /> E H 1425 . SAN JOAQUIN LOCAL�;"HEAi.TH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - FINK-CONTRACTOR <br />