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t <br /> FOR 0_k*IC!_5 USE• APPLICATION FOR WELL. OR .PUMP PERMIT PERMIT NO. <br /> . (Complete_,iinTriplicate} Date Issued: <br /> IS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE T tHE SAN'yy':J��OAQUIN LOCAL'.HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON THI 'APPLICATIOI3 IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN `JOAQUIN 'LOC L'HEALTH DISTRICT. <br /> CENSUS <br /> + e_ CENSUS TRACT: . . <br /> JOB ADDRESS/LOCATION: ��F <br /> � PHONE: <br /> OWNER'S NAME: D CITY: tti <br /> ADDRESS: �' �' <br /> CONTRACTOR'S NAME: lv.4i�T LICENSE �� �- PHONE: �- <br /> I , <br /> INTENDEDUSE: INDIVIDUAL DOMESTIC-WATER.-WELL /,�- PUBLIC::WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELD INDUSTRLAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / OTHER ./ / <br /> t <br /> NEW WELL: DISTANCE TO NEAREST:. .SEPTIC,TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER , <br /> REPAIRS: TYPE OF REPAIRS: <br /> r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> _ a � <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> r <br /> I HEREBY CERTIFY THAT I HAVE PREPAREDVTHIS 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 JOAQU CAL HEALTH STRICT. <br /> SIGNED: CONTRACTOR: <br /> /117 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE III FI <br /> PHASE IINAL <br /> INSPECTION BY: DATE <br /> INSPECTION BY: DATE - 1 <br /> E H 1426 - SAN JOAQUIN LOCAL HEALTH DISTRI1/7�_ <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />