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FOR OFFICE USE: APPLICATION-FOR WELL OR PUMP PERMIT <br /> PERMIT NO. <br /> (Comple'te" in,,Triplicate) Date Issued <br /> T S PERMIT EXPIRES I YEAR- FROM DATE ISSUED • z.,. L <br /> APPLICATION IS HEREBY MADE TO THE SAN ti LOCAL 'HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON.t-' THIS 'APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN-JOAQUIN LOCAL HEALTHY DISTRICT. <br /> JOB ADDRESS/LOCATION: 2Volo . �� � ' c ; �..OWNER'S NAME: p - CENSUS TRACT: <br /> ADDRESS: S ® �L PHONE .�- <br /> CONTRACTOR NAME- CITY: <br /> ter- .•- LICENSE 4i ' PHONE: <br /> :L <br /> INTENDED USE: INDIVIDUAL DOMESTIC,WATER-WELL.k` .PUBLIC,WATER WELL /—/ TEST WELL / ... <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER' WELL /_ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL El- GEOPHYSICAL WELL / / OTHER %/ <br /> NEW WELL: DISTANCE TO NEAREST: SEP IC TANK' <br /> SEWER LINES 5Z? PIT PRIVY /V01y <br /> SEWAGE DISPOSAL FIELDCESSPOOLS-EEPAGE PIT S ER ... <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> � Q <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: - ' <br /> CONTRACTOR: <br /> 'F <br /> PHASE, I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: /9 DATE• <br /> ME <br /> ADDITIONAL COMMENTS: <br /> i — _J - <br /> PHASE II FHASE III FINAL <br /> INSPECTION BY: DATE 3-�y-'�a. INSPECTION BY: J -u DATE <br /> E 1BSAN'JOA VIN LOCAL HEALTH DISTRICT a <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR 1/72 1M <br />