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PERMIT No. <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT Date Issued: <br /> (Complete in Triplicate) <br /> THIS PERMIT EXPIRES.,1 YEAR FROM DATE ISSUED <br /> PERMIT TO <br /> r APPLICATION IS HEREBY MADE TO THE SAN JOAQUiN LOCA INCOHEALTHICT OR ORDDINANCEERFORM <br /> THE WORK STATED HEREON:I . THIS APPLICATION IS MADE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> hF CENSUS TRACT: S# S� • <br /> JOB ADDRESS/LOCATION: I '" PHONE: <br /> OWNER'S NAME: CITY: ` <br /> ADDRESS: LICENSL PHONE: r <br /> CONTRACTOR'S NAME: ' <br /> f <br /> _ TEST WELL /7 _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER <br /> AGR CULTURAL/WATER WELL PUBLIC �IEI INDUSTRIAL WATER WELL /J <br /> IRRIGATION/LIVE <br /> C_ATHODIC PROTECTION WELL / / GEOPHYSICAL WELL OTHER — -- <br /> SEWER LINES PIT PRIVY <br /> NEW WELL: DISTANCE TO NEAREST: <br /> SEPTIC TANK <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> i44 <br /> I <br /> REPAIRS: TYPE OF REPAIRS <br /> L '► <br /> i i A U <br /> i <br /> Lo <br /> � . <br /> " ABANDONMENT/DESTRUCTION: METHOD TO BE USED., <br /> PLOT PLAN: . SHOW ON REVERSE SIDE - " <br /> I HEREBY CERTIFY THA I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCEM-WITH THE PROVISIONS OFT THE <br /> LAWREGULATIdNS-OF TATE OF THECSANIFOOAQUIN RNIALOCAL ORDHEALTHSDOISTRICT. <br /> COUNTY OF SAN OAQUIN, AND THE <br /> CONTRACTOR: P ' <br /> SIGNED: lee <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: a DATE: _—Z-0--2 _ <br /> ADDITIONAL COMMENTS: <br /> M' PHASE III FINAL <br /> PHASE.�II k2 . <br /> � DATE <br /> ION BY: _ DATE INSPECTION BY: L1.� <br /> INSPECT 172 <br /> E H 1426 4 SAN JOA UIN. LOCAL HEALTH DISTRICT <br /> ER - PINK-CONTRACTOR <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWN <br />