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FOR OFFICE USE: APPLICATION.FOR .WELL OR PUMP PERMIT PERMIT NO 21 z ' <br /> _ {Complete „in,Triplicate} <br /> 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 /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. j <br /> JOB ADDRESS/LOCAT N: Q"� a CENSUS TRACT: <br /> OWNER'S NAMEIF PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME' "' 1 LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL <br /> WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> 1 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> h SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> � Y <br /> t d <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE A <br /> f <br /> i 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 /> � r <br /> j SIGNED: CONTRACTOR: <br /> i' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. DATE: —/- 7Z <br /> G ADDITIONAL COMMENTS: <br /> PHASE II PHASE I/FINAL <br /> INSPECTION BY: DATE INSPECTION B DATE <br /> E H 1426 t SAN JOAQUIN LOCAL HEALTH DISTRICT 1/I2 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT— YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />