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FOIL OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: �v <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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: rJ CENSUS TRACT: <br /> OWNER'S NAME: a PHONE: <br /> ADDRESS: P� CITY: <br /> CONTRACTOR'S NAME: EN At LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL f ---PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK./AGRICULTURAL-WATER WELLINDUSTRIAL WATER WELL <br /> / / JJ <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES �PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELDS('( CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS; <br /> .J <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE -SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK'WILLIBE 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 RUE AND REGU TI OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: x CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: �� CJ --^�_` DATE: <br /> ADDITIONAL COMMENTS: ' ' -' <br /> PHASE II PAASE III FINAL <br /> INSPECTION BY:� �� DATE ^��3 7� INSPECTION BY: D ` o� ' <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION; WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - FINK-CONTRACT <br />