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FOR OFFICE USE: - � 'LICATION FOR WELL OR PUMP PE76ifk E1 XT N4. 7 L- 9ti <br /> __(Complete in Triplicate) 11) ssued: :1-I y 'v <br /> THIS PERMIT EXPIRES I 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 /> .TOB ADDRESS/LOCATLON: 6 37v� .C, CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 3 7 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 f_1 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / 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: f <br /> • J <br /> ' Al <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 9 <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> f <br />'k <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: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` I� <br /> APPLICATION ACCEPTED BY: DATE: fo <br /> ADDITIONAL COMMENTS: u - <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE J-/(-72- <br /> E <br /> `/('72- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH_DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR 1A <br />