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L v <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> d (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . , <br /> APPLICATION IS HEREBY MADE TO THE SAN 'JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATEWHEREON. 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: <br /> OWNER'S NAME: CENSUS TRACT: <br /> PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: - LICENSE 4 l o s PHONE: 6 / <br /> If <br /> INTENDED USE: _ INDIVIDUAL . MESTIC WATER WELL / / 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 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ^0 <br /> V <br /> I ' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED. <br /> f � <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 TH LES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMEg USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: _ 4 tet '�'-a DATE: .� <br /> ADDITIONAL COMMENTS: <br /> PHASE TI PHASE III/FINAL f <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOA UIN -LOCAL HEALTH DISTRICT 1/72 ]M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />