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' FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z Z L <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 n� <br /> THE WORK STATED HEREON. THIS APPLICATION IS �MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1$62 AND RULES AND REGULATIONS OF THE SANJOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: S2 7 CENSUS TRACT: <br /> OWNER'S NAME: art PHONE: <br /> ADDRESS: CITY: ; <br /> CONTRACTOR'S NAME: LICENSE # / PHONE: <br /> Z <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL: PUBLIC WATER WELL /—/ TEST WELL f / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f f GEOPHYSICAL WELL %/ OTHER / / <br /> W <br /> qt <br /> NEW WELL: DISTANCE TO NEAREST: �EPZI SELINES ITSEWAGE DISPOSAL FIELCESSP OL SEEPAGE P T OTR <br /> �� - <br /> t <br /> REPAIRS: TYPE OF REPAIRS: , <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> E �o <br /> : y f <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: ta, } Q, CONTRACTOR: AZt7i <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: / <br /> ADDITIONAL COMMENTS: t <br /> i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: 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 />