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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -z-y. <br /> (Complete in Triplicate) Date Issued: L- Y <br /> S 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: 'I I 9YI z-- LQU CENSUS TRACT: ` <br /> OWNER'S NAME: P2129 m2v ! PHONE: � g !(o. <br /> ADDRESS: IffCITY: �s AAaw <br /> CONTRACTOR'S NAME: LICENSE # PHONE: 7 <br /> r <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /Z?�­PUBLIC WATER WELL / / TEST WELL f-1 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL/—/ GEOPHYSICAL WELL/_/ OTHER <br /> NM- <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 /> u <br /> ., N <br /> m <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 1 <br /> . I <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 $ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASrE� III FINAL <br /> +� V f <br /> INSPECTION BY: DATE INSPECTION BY: DATE -- �f- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH_DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />