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FOR OF ICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ?y Z <br /> .�` (Complete in Triplicate) Date Issued:Z 7 <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t <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 /> i JOB ADDRESS/LOCATI N: �p CENSUS TRACT: <br /> OWNER'S NAME: PHONE: G. S <br /> ADDRESS: 6 0 k/- CITY: <br /> CONTRACTOR'S NAME: LICENSE # 16�37� PHONE: <br /> + INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /''/ PUBLIC WATER WELL j / TEST WELL /-7 _ <br /> IRRIGATION/LIVESTOCK AL/AGRICULTURWATER WELL / /_INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL. WELL / / OTHER <br /> NEW WELL: DIST ST: TIC TANK LINE �' PITP�SEWAGE D�TONr <br /> IELD OOL SEEPAG T <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTR TION: MET 0 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 JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: QI� <br /> k r-i-e <br /> i <br /> k ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY: & DATE: f� / <br /> ADDITIONAL COMMENTS: <br /> PHASE II BASE III FINAL <br /> -INSPECTION BY: DATE INSPECTION BY: DATE 6 / <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR C . <br />