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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. r] 2- 'S L <br /> ` (Complete in Triplicate) Date Issued: / 7--7 I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <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: CENSUS TRACT: <br /> OWNER'S NAME: PHONE: 3 7 <br /> ADDRESS: o CITY• y <br /> CONTRACTOR'S NAME: LICENSE # 1' 0.fZ PHONE: E� >4 >/ T <br /> INTENDED USE: INDIVIDUAL MESTIC WATER WELL j J PUBLIC WATER WELL / / TEST WELL /� <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL #--7' INDUWELL f-1 <br /> WATER WE /_/ <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 /> 1 <br /> REPAIRS: TYPE OF REPAIRS: f7 <br /> d <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 4 <br /> �j <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WI .L BE DOME IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OZSOAQUIN, AND -T ULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGN : W , CONTRACTOR: <br /> FOR DEP ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBY: DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE -,_ INSPECTION BY: 667 DATE 3`42-J <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />