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j 1 ) _ 3za - (0 <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. & <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 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 /> r <br /> JOB ADDRESS/LOC ION: ly ' CENSUS TRACT: <br /> OWNER'S NAME: PHONE:. . T— <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME* _ rt .a �}„ , LICENSE'# PHONE: AZ <br /> INTENDED USE: INDIVIDUAL.DOMEESTI�C WATER WELL PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK f® � SEWER LINES ! PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: , a <br /> iz <br /> a <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE 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: F�7 CONTRACTOR: <br /> FOR DEPAR ENT USE ONLY <br /> PHASE I ,/� �- <br /> APPLICATION ACCEPTED BY: DATE: Z— <br /> ADDITIONAL COMMENTS: <br /> PHASE II ) PRASE III FINAL <br /> INSPECTION BY: W DATE l/ INSPECTION BY: DATE <br /> E H ,1426 . S OA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK--CONTRACTOR <br /> Yam <br />