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[FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> -3 <br /> (Complete in Triplicate) Date Issued: <br /> IS PERMIT EXPIRES '1 YEAR FROM DATE ISSUED <br /> ( q3 7o) <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 REGUTATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: 91 1 c1 ✓ CENSUS TRACT: <br /> OWNER'S NAME: kib / PHONE: <br /> ADDRESS: t C'' CITY: �� X17 <br /> CONTRACTOR'S NAME: LICENSE It HONE: ���. � <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /� _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURALATER WELL / /_INDUSTRIAL WATER WELL'/ / <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL / / OTHER f / <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: a <br /> C' <br /> — — <br /> t <br /> f <br /> l0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> i # <br /> PLOT PLAN: SHOW ON REVERSE !SIDE <br /> k <br /> I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE VISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JO IN E RUL AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 1 _ <br /> SIGNED; G CONTRACTOR: <br /> f FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED BY: �_ DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1425SAN JOAQUIN LOCAL HEALTH DISTRICT �, / ��►.Yoda/ t,,,a T 1M ' <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> 7e�bf'o. ISD /F, �, W; S <br />