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FO OFFICE USE: APPLICATION FOR WELL .OR PUMP PERMIT PERMIT NO. <br /> • (Complete is Triplicate) Date Issued: ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY UE.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. fo 3 cr'��• CENSUS TRACT <br /> y' OWNER'S NAME: PHONE: <br /> ADDRESS: T G CITY: ' <br /> CONTRACTORS NAME: LICENSE #X43 _ PHONE: _ <br /> INTENDED USE: INDIVIDUAL-.DOMESTIC WATER WELL L__7 PUBLIC WATER WELL /_/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL .WATER WELL / INDUSTRIAL WATER WELL /� <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL-7 / OTHER J% <br /> r <br /> f ' <br /> 4 <br /> -NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER. <br /> . h <br /> REPAIRS: TYPE OF REPAIRS: qA 5 lei l <br /> 4 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> G <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, 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: <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ .„ INSPECTION BY: DATE 3-30 <br /> E H 1426 - SAN_JOAQUIN LOCAL HEALTH DISTRIC 1/72 1M <br /> DISTRIBUTION: WH TE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER PINK-CONTRACTOR �Y <br />