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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ' 7 2--7 ' S <br /> (Complete in „Triplicate). Date Issued: ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY DE 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' ~� CENSUS TRACT: S6” <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: , - CITY: <br /> CONTRACTOR'S NAME: LICENSE PHONE; <br /> INTENDED USE: INDIVIDUAL .DOMESTIC-WATER WELL - ..PUBLIC..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 _ J <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> r <br /> REPAIRS: TYPE OF REPAIRS: 0-4:Ld4d <br /> 4 <br /> A.. <br /> ABANDONMENT/DESTRUCTION; METHOD TO BE USED: T <br /> PLOT PLAN; SHOW ON REVERSE SIDE 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 REGUJoATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: � _ �- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: _/' _ DATE: O - <br /> ADDITIONAL COMMENTS: <br /> ZA <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: 11;V DATE 7e9, <br /> E H 1426 1 . SAN JOAQUIN LOCAL HEALTH DISTRICT_ 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />