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FOR OFFICE USE: APPLICAT N FOR WELL OR PUMP PERMIT PERMIT N0. <br /> Complete in Triplicate) Date Issued: 2-' <br /> THIS PERMIT EXPIRES 1 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 REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> JOB ADDRESS/LOCATION: <br /> CENSUS TRACT: <br /> OWNER'S NAME: - - PHONE: -- <br /> ADDRESS; CITY: <br /> CONTRACTOR'S NAME: /-- ! LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTU L WATER WELL / /_INDUSTRIAL WATER WELL <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 /> Y <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED.* <br /> y r <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> yr <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 /> SIGNID: . ��� �. - - CONTRACTOR: <br /> FOR DEPARTMENT USE ONLYr <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ! <br /> DATE: l3 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> i <br /> INSPECTION BY• DATE INSPECTION BY: DATE y <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - -YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />