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FOR `OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: zz -7 z <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED i <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/LOCAT � �f� �� � �L1N/Z)�E_NSUS TRACT: <br /> ` - - -- -- - <br /> OWNER'S NAME: �,e - PHONE: <br /> ADDRESS: / 7—E: 7:-TX <br /> CONTRACTOR'S NAME: J z��TJ LICENSE �� 3V PHONE: � e, 3 <br /> - - - <br /> INTENDED USE: INDIVIDUAL DO TIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /L/— LL <br /> INDUSTRIAL WATER WE <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /_/ OTHER / / <br /> NEW WELL: DIST TO NEAREST: SEPT SEWER PIT PRIVY <br /> SEWAGE DI FIELD CESSPOD EPAGE PIT .OT �, <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION:.'' METHOD kTO BE USED: � <br /> PLOT PLAN: SHOW ON REVERSE SIDE i <br /> 1 <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 /> t <br /> SIGNED: 1 � CONTRACTOR: <br /> s <br /> P-0- rgt 111-7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: a.t�� DATE: I � ' .' <br /> ADDITIONAL COMMENTS: <br /> PHASE IT PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />