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FOR OFFICE USE: APPLICATION FOR Wk OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: 3 <br /> HIS 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 REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: _ /ALL CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 10 AA jA CITY; <br /> CONTRACTOR'S NAME: LICENSE # }PHONE: <br /> INTENDED USE: INDIVID AL DOMESTIC WATER WELL /'/ PUBLIC WATER WELL`/ / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL, 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 /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: f <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 THERULESAND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: � � � J CONTRACTOR: f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: L� A//, , <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY DATE ��1 7fk <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRIC 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />