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FOR OFFICE USE: III, /Vy y APPLICATION FOR WELL OR PUMA' PERMIT PERMIT N0. <br /> E (Complete in Triplicate) � D <br /> IM THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i <br /> 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 /> �I <br /> JOB ADDRESS/LOCA T ON: <br /> ' TRACT: <br /> OWNER'S NAME; <br /> ADDRESS: v PHONE: <br /> CONTRACTOR'S CITY: R <br /> LICENSE #) /„ PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBIC WATER WELL E17 TEST WELL E7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WEI,L _INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WE L / / OTHER / <br /> I <br /> WELL: DIQSTANCE 'T6ikNEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE-bi'SPOSAL FIELDCESSPOOL SEEPAGE PIT OTHER ' <br /> � <br /> � A J <br /> AIRS: TYPE OF REPAIRS: <br /> RE <br /> i { <br /> ABx ANDONMENT/DESTRUCTION: METHOD TO BE USED; <br /> y - <br /> PLOT PLAN;-- SHAW ON REVERSE SIDE t <br />--I. HEREBY,GERTIFY"THAT,I HAUE„PREP-ARED�THIS.t.APPLICATION-AND-THAT_THE WORK_WIL <br /> L_BE DONE_IN <br /> ACCbRDANCE•WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THEA <br /> COUNTY' OFSAN'JOAQUTN, AND HE RULES AND 'REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: kt'_ 'i CONTRACTOR: <br /> I� <br /> PHASE I �f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ,� DATE: 7� <br /> ADDITIONAL COMMENTS: <br /> PHA PHASE III FINAL INV\A <br /> INSPECTION BY: i� DATEIT <br /> INSPECTION BY: DATE ;�-/0''>.4, <br /> E H 1426 SAN .JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE HEALTH DISTRICT - YELLOW= <br /> i=PROPERTY OWNER - PINK-CONTRACTOR <br /> II " <br />