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FOCI OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. L Z <br /> (Complete in Triplicate) Date Issued: - <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MAD$ THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK. S'L'ATED 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: ILYL / wz.,C'-�' ,zz"..,..__. CENSUS TRACT: <br /> OWNER'S NAME PHONE: <br /> ADDRESS: J 2.-a i CITY: 4, , <br /> CONTRACTO 'S NAME: , P fJ LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTU L WATER WELL /—/ INDUSTRIAL WATER WELL f_1 <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL /_/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPT3C TANK SEWER LINES �PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD jQ� CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> n <br /> PLOT PLAN: SHOW ON REVERSE SIDE I <br /> I <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: 4�n-lir. ��.C �•,�.�. _---- CONTRACTOR: <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: 7-' 31 7z- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: / DATE 7­31-2 INSPECTION BY JC.. DATE " <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR w�� <br /> { <br />