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FOR OFFICE USE: , 1 APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: r ?j <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 /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �" N CENSUS TRACT: <br /> OWNER'S NAME. I PHONE: _ � '�'�Z p " <br /> ADDRESS: ' CITY: <br /> CONTRACTOR'S NAME:" /' LICENSE 4E f� PHONE: 3 L <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL jf'FINDUSTRIAL 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: c.-e.. /tea L <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE -USED- <br /> PLOT <br /> EUSED-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 /> ;A <br /> COUNTY OF SAN JOAQUINND THE RULES AND REGULATIONS OF THE SAN JOAQU1INN LOCAL HEALTH DISTRICT. r <br /> SIGNED: �.,.1 CONTRACTOR: <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: ? f 7 L <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY. DATE <br /> E H 1426 _SAN JOAQUIN_LOCAL_HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />