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FGR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. (, <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES l YEAR FROM DATE .ISSUED <br /> t <br /> APPLICATION IS HEREBY MADE 0 THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN'COMPI,IANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HE STH DISTRICT. <br /> JOB ADDRESS/bee�@N! 7 cc ,- Y CENSUS TRACT: <br /> OWNER'S NAME: r I PHONE: <br /> ADDRESS: � Q CITY: f <br /> CONTRACTORS NAME: ,� LICENSE # �7z 3 V 3 PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTU WATER WELL -/.-/_., INDUSTRIAL WATER WELL <br /> CATHODIC-PROTECTION- WELLGEOPHYSICAL WELL OTHER- <br /> NEW WELL: DISTANCE TO`NEAREST: SEPTIC TANK,'50 SEWER LINES PIT PRIVYUYk <br /> SEWAGE DISPOSAL FIEL CESSPOOL SEEPAGE PIT -OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ♦r <br /> J <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> r <br /> PLOT PLAN: SHOW ON REVERSE SIDE ' <br /> I HEREBY CERTIFY THAT I HAVEIPREPARED 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 /> k COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> f <br /> i <br /> SIGNID <br /> ae► �,, r � x s .`CONTRACTOR .►. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: - _ Vv'l� DATE: ' <br /> ADDITIONAL COMMENTS: <br /> f PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 .4 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-. EALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR A <br />