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PERMIT NO. <br /> FOR lOFFICE USE• APPLICATION FOR WELL 'OR;PUMZ PERMIT Date Issued: '8'- 9-�3 <br /> (Complete' in Triplicate) <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED <br /> APPLICATION IS <br /> 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 D 23 <br /> NO. 1862 AND RULESIAND--REGU TIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. 2 0�_2 <br /> CENSUS TRACT: <br /> .TOB ADDRESS/LOCATION: +5 PHONE <br /> OWNER'S NAME: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: <br /> -_ ,,. - - - �'LICENSE �� �_ PHONE <br /> LL <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL, ]FL,/, ' PUBLIC WATER WELL TEST <br /> WE WELL f / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /� <br /> CATHODIC PROTECTION WELL / I GEOPHYSICAL WELL Lf OTHER / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK �i SEWER LINES � — PIT PRIVY d ^4 <br /> SEWAGE DISPOSAL FIELDS CESSPOOL SEEPAGE PIT OTHER — -Z <br /> Z, <br /> F REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: I <br /> l <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> r 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 IN, AND THE RULES AND REGULATIONS�v'0 THE SAN JOAQUIN LOCAL HEALTH DISTRICT.. <br /> CONTRACTOR: ' <br /> SIGNED: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE III FINAL <br /> PHASE II <br /> INSPECTION BY: DATE <br /> INSPECTION BY: ! DATE <br /> E H 1426 SAN JO 1UIN LOCAL HEALTH DISTR 172 IM <br /> PINK-CONTRACTOR <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - <br />