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LL(3 <br /> FO OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. -]3-LO Y \,/ <br /> (Complete in Triplicate) Date Issued: , �_ <br /> THIS 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 /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION:, CENSUS TRACT: <br /> OWNER'S NAME: ' PHONE: <br /> ADDRESS: 01 CITY: <br /> CONTRACTOR'S NAME: LICENSE PHONE:8 !L6 -1- <br /> 0 <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL /,G/ PUBLIC WATER WELL /_/ TEST WELL /7 � <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /-7/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / f GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE .TO NEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> f <br /> REPAIRS: TYPE OF REPAIRS: <br /> OIL a: <br /> v <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: <br /> �� DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE J�`2�� - INSPECTION BY: ATE <br /> E H 1426 ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br /> z <br />