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FOR OFFICE USE: f"�LICATION FOR WELL OR PUMP PERM PERMIT T NO. 3 <br /> Complete in Triplicate) Date Issued: �� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMITPERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDI AE <br /> 0 NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. € <br /> JOB ADDRESS/LOCATION: <br /> OWNER'S NAME: i CENSUS TRACT. <br /> ADDRESS: PHONE: 9 g 2„ � �-/ <br /> �I �� G G CITY: _".. <br /> CONTRACTORS NAME: 4tICENSE # ;Z�-7(ei 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 / / OTHER <br /> NEW WELL DISTANCE TO NEAREST: SEPTIC TANK tj#AIXEWER LINES PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> 9 01 <br /> REPAIRS TYPE OF REPAIRS.- .$.714 L[_ / / <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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: CONTRACTOR: fa tV fVeRSAL <br /> PHASE I 1�-M 54p cy <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> i <br /> PHASE Y PHASE III FINAL . <br /> INSPECTION BY: DATE INSPECTION BY: / DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT �- 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />