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FOR OFFICE tJS APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: c <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED <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/LOCATION:d,t f' j(roPI��CEUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: Gi. ' A S CITY: A 111A <br /> CONTRACTOR' NAME: LICENSE # PHONE: /o <br /> C 6�- <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL &_7 PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL-/_/ OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK jib' SEWER LINES //d';PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS., TYPE OF REPAIRS: <br /> Lq <br /> fi <br /> n <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: (� <br /> 1074e. <br /> Ll <br /> i <br /> PLOT PLAN: SHOW ON R ERSE 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 JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. � <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY: I a o z/-- DATE: / <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III F1NAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE ;?.-7- -_ <br /> E H 1426 _SAN JOAQUIN LOCAL HEALTH_DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />