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i FOR OFFICE USE: APPLICATION <br /> FOR WELL OR PUMP PERMIT PERMIT NO. <br /> i . (Complete in Triplicate) R Date Issued: <br /> IS PERMIT EXPIRES I YEAR FROM DATE ISS ED - <br /> E I E <br /> APPLICATION IS HEREBY MADE TO THE 'SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> i' 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 ;2 O / k CENSUS TRACT: <br /> OWNERS NAME: PHONE: <br /> ADDRESS: 5'� CITY: <br /> CONTRACTOR' NAM LICE E # �_ PHONE: <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL 7 PUBLIC WATER WELL / / TEST WELL /_7 <br /> E IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER /_7 <br /> f <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER ES PIT VY <br /> SEWAGE DISPOSA IELD CESS SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> a <br /> E <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ;;. <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> E � <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: <br /> CONTRACTOR: ug) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: `"� ��—�?�° DATE: %0_1112 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE II FINAL <br /> INSPECTION BY: DATE INSPECTION BY: TE �r� 7— <br /> E H 1426 *. SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />