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FOR OFFICE USE: APPLICATION FOR'WELL OR PUMP PERMIT PERMIT NO. ] <br /> '\ (Complete in ,Triplicate) Date Issued: z.'- 7-.-7 <br /> THIS PERMIT EXPIRES I 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 ULATI NS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION! / � 07�.�+ �� ENSUS TRACT: <br /> OWNER'S NAME: 0 2.ca PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE # 'HONE: ' <br /> I <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL 7— PUBLIC WATER WELL �/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /� INDUSTRIAL WATER WELL /� <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / . OTHER <br /> NEW WELL: DISTANCE TO T: S IC TANK S LINES PIT IVY <br /> SEWAGE DISPO FIELD CESSPOOL EEP E �PIT OTHER' /// <br /> l <br /> REPAIRS: TYPE OF REPAIRS: t , <br /> 00 <br /> ;I J ' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I �L <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> ' I <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVIJRULES <br /> THE LAWS OF. THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, ANAND REGULATIONS OF-THE SAN JOAQUI OCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY �€€ <br /> PHASE I f <br /> APPLICATION ACCEPTED BY: r DATE: <br /> ADDITIONAL COMMENTS: <br /> •� i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: fJ'/A DATE INSPECTION BY: DATE <br /> E H 1426 " : SAN JOAQUIN LOCAL HEALTH DISTRI 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR G <br />