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FOR..OFFIrrE USE: APPLICATION FOR WELL OR PUMP PERMIT / <br /> PERMIT N0. I <br /> (Complete in Triplicate) Date Issued: <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. 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/LOCATION: �� � our <br /> OWNER'S NAME: N "��� CENSUS TRACT <br /> ADDRESS: 'fl-107 PHONE: 36b - 11-79- <br /> CONTRACTOR'S NAME: CITY: <br /> LICENSE 4� � PHONE: Z <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL /Pr PUBLIC WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /%_INDUSTRIAL WATER WELL / <br /> CATHODIC PROTECTION WELL I I GEOPHYSICAL WELL— <br /> 'Cl- OTHER <br /> NEW WELL: DISTANCE TO N SEPTIC TANK SEWER LI PITIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL S GE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> h <br /> Z <br /> ABANDONMENT/DESTRUCT ON: MET OD TO BE USED: S <br /> a <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HER Y CERTIFY THAT HAV PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCO ANCE WITH THE P VISI NS OF HE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUN OF SAN JOA UI , . HE L LES REGULATIONS OF THE SAN JOAUIN LOC DISTRICT. <br /> SIGNED: ,/�. < r "�-14�� CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: f2 DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II! PHASE III FINAL <br /> INSPECTION BY: ' r DATE Z-.2 .3- 7:)- INSPECTION BY�>Y - <br /> DATE .2--2 7 ]-�.v <br /> E H 1426 . SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />