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FOR OFFICE USE: APPLICATION FOR WELL' OR PUMP PERMIT PERMIT NO. -0 <br /> (Complete in Triplicate) Date Issued: � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LO ON: C 1 �. CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 4v CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /-T PUBLIC WATER WELL X/- TEST WELL /- _ <br /> t IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /-7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL L_1 GEOPHYSICAL WELL L/ OTHER <br /> i <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 /> RL <br /> AM-Mwas;- Ica- <br /> n11 ff / <br /> &A- - <br /> ABANDONMENT/DESTRUCTION: HOD TO BE USED: <br /> t <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 J QUI: THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> I <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: 2 _2, <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> k <br /> INSPECTION BY: DATE INSPECTION BY: 19VOZ�—DATE <br /> E' H 1426 ' SAN JOAQUIN LOCAL HEALTH DISTRICT . 1/72 1M <br /> '.DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />