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�yCsvu_. lJn.a.pv� <br /> FOR OFFICE <br /> APPLICATION FOR WELL OR PUMP PERMIT <br /> (Complete in Triplicate) PERMIT NO. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued: � b <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 C <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DIS <br /> OLINTY ORDINANCE <br /> JOB ADDRESS/LOCATION: DISTRICT. <br /> OWNER'S NAME: CENSUS TRACT: <br /> ADDRESS. i <br /> CONTRACTOR'S NAME: PHONE: <br /> LICENSE # CITY: . <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PHONE: �.�� �y <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL/WATER LWELLA/E WELL /% TEST WELL <br /> CATHODIC PROTECTION WELL /_I <br /> // GEOPHYSICAL NDUSTRIAL WATER WELL <br /> SICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE"DISPOSAL FIELD SEWER LINES PIT PRIVY <br /> CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: 12 <br /> r f W <br /> ABAN1}ONMENT/DESTRUCTION: METHOD TO BE USED: <br />�PLOTPLAN; SHO=R=VERS=SID�E��� A <br /> n <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA OR IN DONE IN <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL ORDINANCES OF THE <br /> SIGNED: Q HEALTH DISTRICT. <br /> CONTRACTOR: <br />'HA� E I FOR DEPARTMENT USE ONLY <br /> - o <br />►PPLICATION ACCEPTED BY: � <br /> iDDITIONAL COMMENTS: DATE: C1 <br /> PHASE II <br /> PHASE III/FINAL <br /> NSPECTION BY: DATE n/� <br /> H 3426 INSPECTION BY: [1 DATEMN o <br /> CSTRIBUTION: HEALTH DISTRICT JOAQUIN YELLOW-PROP ERTYT OWNER ICPINK- <br /> WHITE-- I/72 � <br /> CONTRACTOR <br />