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FOR OFFICE USE: APPLICATION FOR WELL .OR PUMP PERMIT PERMIT NO. -72, -1 .5. <br /> (Complete in Triplicate) Date Issued: /- -7 <br /> S PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> V 1 <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 LOCA HEALTH DISTRICT. <br /> JOB�AD SS/LOCATION: � [.� 4,3 0C�S S TRACT: l E-3-/10 0.3 <br /> OWNER'S .NAME: �� irk PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR"S NAM: LICENSE ! ' PHONE: Z- <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /7 PUBLIC WATER WELL-/ / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL j INDUSTRIAL WATER WELL /� <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL OTHER <br /> NEW WELL: DISTANCE O NEA71'ELD <br /> : SEPT TANK <br /> S LIN P PRI H � <br /> SEWAGE SPOSAL CESSP SEEPAAE PIT OT R <br /> REPAIRS: TYPE OF REPAIRS �1G�?t.� �� <br /> e t <br /> I � <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 J AQUIN, THE RULES AND REGULATIONS OF THE SAN JOAQUIN CAL HEALTH DISTRICT. <br /> t SIGNED: CONTRACTOR: <br /> ,.,.. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE I PHASE III FINAL <br /> INSPECTION BY: y DATE INSPECTION BY: DATE -�S"�a. <br /> E H 1426 SAN JOA UIN LOCAL REALTH DISTRICT 1172 <br /> DISTRIBUTION: ITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR C <br />