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FOR OFFICE USE: APPLICATION FOR WELL 'OR POMP PERMIT PERMIT NO. ' -'2 <br /> (Complete"in,•Triplicate) Date Issued: <br /> w <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 /> THE WORK STATED HEREON. 'THISAPPLICAT ON IS MADE' II3:COMPLIANCE 'WTH COUNTY ORDINANCE <br /> NO. .1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: Z.?Sr'`2-` 'E I4v <br /> CENSUS TRACT* <br /> PHONE: <br /> OWNER'S NAME: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: " LICENSE - PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC• WATER WELL-PUBLIC-WATER WELL / /. TEST-WELL. / <br /> IRRIGATION/LIVESTOCK%AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER / <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 /> v <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> A <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 /> CONTRACTOR: <br /> SIGNED: <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY: DAT. : <br /> ADDITIONAL COMMENTS: <br /> PHASE III FINAL <br /> PHASE II <br /> t <br /> INSPECTION BY: DATE _ _ INSPECTION BY:-To Q9 0 DATE <br /> E H 1426 -L SAN'"JOAQUIN`LOCAL HEALTH DISTRICT 1.72 - 3.M <br /> DISTRIBUTION: " WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />