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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> C (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 /> r. THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> L--NO•.�3862-AND- RUL E-S-AND-REGULATIONS-:OF-THE SAN�JOAQUIN-:-LOCAL:HEALTH,bISTRICT- <br /> At { <br /> JOB YADDRESS/LOCATION i &51190[� i' CENSUS TRACT: <br /> OWNER'S NAME: <br /> PHONE: <br /> ADDRESS: ,�6 p-,� �3 <br /> �• ` CITY: <br /> CONTRACTOR'S NAME: CENSE &1 54_f PHONE: - Y6ya <br /> I -- <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL J / PUBLIC WATER WELL El- TEST WELL /_7 <br />! IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL 2/ INDUSTRIAL WATER WELL %J <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL./ _/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 5P,00 SEWER LINES 9oa SPIT PRIVY <br /> j SEWAGE DISPOSAL FIELD —^ CESSPOOL SEEPAGE PIT — OTHER <br /> REPAIRS: TYPE OF REPAIRS: , <br /> h � 4 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: , <br /> t � i <br /> 1 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> { <br /> 4 <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: J CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> -� ✓��- <br /> ADDITIONALCOMMENTS t---T-� -.. .- -- <br /> PHASE II PHASE III FINAL <br /> r . . <br /> INSPECTION BY: DATE _ -- INSPECTION BY: DATE <br /> E H 1%+26 ' SAN JOAQUIN LOCAL HEALTH DISTRICT:-; 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />