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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z-L'3 <br /> (Complete in Trip.Iicate) Date Issued: ti- 7z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> , <br /> s <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> ; . a <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE INCOMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQU N LOCAL HEALTH DISTRICT. i <br /> JOB ADDRESS/LOCATION: w CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: rJ - / CITY: <br /> CONTRACTOR'S NAME: .4'i1 ;, p, - LICENSE # 3 7,3 PHONE: _416G_r625 ` <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /kk--P-UBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL I / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL L_1 GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO N � SEPTIC�K SEWER LINE PT YRIxy <br /> SEWAGE�POSAL FIEL CE5SP40L SCEP GE PIT" R <br /> i <br /> REPAIRS: TYPE OF REPAIRS: <br /> iM a <br /> ml <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: CONTRACTOR: <br /> �I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �� j DATE: <br /> ADDITIONAL COMMENTS: Iil. <br /> N <br /> PHASE II PHASE III/FINAL o p <br /> INSPECTION BY: Ia_ DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL-HEALTH DISTRI 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> t <br /> 1 II C�11-' <br />