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FOR OFFICE USE: <br /> Al 'CATION FOR WELL OR PUMP PERMI` <br /> PERMIT NO <br /> v (Complete in Triplicate) Date Issued: y <br /> IS PERMIT 'EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOQA <br /> 1M <br /> THE WORK STATED HEREAFTER, THIS APPLICATION IS MADE IN COMPLIANCE WITNEORM <br /> N0. 1862 AND RULES AND REGULATIONS. <br /> JOB ADDRESS/LOCATION': �x1 -$'NEEdI <br /> OWNER'S NAME: CENSUS TRACT: <br /> �P��' / - �i E PHONE: <br /> ADDRESS: f Z / 7 <br /> r " <br /> CONTRACTOR'S NCITY: f VC-4 crwr <br /> AME: I d+ o C ,-„� r. , LICENSE �� `'�: , .;' PHONE: �� 7 <br /> ` <br /> INTENDED USE:' INDIVIDUAL DOMESTIC WATER WELL / // PUBLIC WATER WELL /% TEST WELT, <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL; WATER WELL / / INDUSTRIAL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER WATER WELL <br /> NEW WELL: DISTANCE TON � � � <br /> NEAREST'. SEPTIC. TANK /CD SEWER LINES PIT PRIVY GD SEWAGE <br /> DISPOSAL FIELD ,CESSPOOL/SEEPAGE PIT OTHER II <br /> ,t <br /> REPAIRS: TYPE OF REPAIRS: � . <br /> J <br /> �I <br /> ABANDON/DESTRUCTION: ; METHOD TO BE USED : <br /> IM <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I� <br /> I HEREBY CERTIFY THA'T� I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN I 4 <br /> ACCORDANCE WITH SAN JOAQUIN CO "ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF THEA 4 <br /> SAN JOAQUIN L- -CAL ALT DISTR CT. ,r <br /> SIGNED: <br /> CONTRACTOR: <br /> IR <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ..,. ;CEPTED BY:. r 7 tl� DATE: <br /> , <br /> ADDITIONAL RENTS: / <br /> PHASE .'III� <br /> PHASE III FINAL !!° N <br /> INSPECTION BY:, DATE DATE �- 1 t f 7� I� <br /> .a _ <br /> SAN JOA UIN LOCAL HEALTH DISTRICT �� MAV 1441. <br /> E0HyG -�t , j, i <br /> i� <br /> y e <br />