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� FOR OFFICE USE: Al'PT;ICA FOR WELL QR PUMP PERMIT PERMIT NO. " <br /> (Complete in Triplicate} Date Issued: <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> ` THE WORK STATED HEREON. THIS APPLICATION IS"MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> JOB ADDRESS/LOCATIO ZCENSUS TRACT: <br /> OWNER'SFNAME: PHONE: 3 <br /> ADDRESS: c CITY: <br /> CONTRACTOR'S NAME: LICENSE #/ �j,� PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL, WATER WELL f7_7 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 p , <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> �rf <br /> 1 <br /> y i <br /> 1 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br />—I .HEREBY?CERTIFY-TAA -T-i#AVE-PREpA ED�THIS IPPI;ICE�TION'�A1�1�?"THAI'`THE WO 'WILL E 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 /> SIGNEP. /L�-a. .� CONTRACTOR: <br /> FOR DEPARTIONT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ,f 7 <br /> ADDITIONAL COMMENTS: <br /> sJ DATE <br /> r <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> DATE - -��- <br /> E H 1426 SAN_JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M ` <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />