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FOR"OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 1. <br /> (Complete in Triplicate) Date Issued: Z L <br /> ;H S 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 /> 'HE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> 10. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SOB ADDRESS/LOCA ON: CENSUS TRACT: <br /> IWNER'S NAME: • A A PHONE: <br /> ,)DRESS: CITY: <br /> :ONTRACTOR'S NAME: LICENSE 4f PHONE: <br /> NTENDID USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL /—/ TEST WELL L-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL / J <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL /_/ OTHER <br /> fEW WELL: DISTANCE TO NEAREST: SEPTIC TANKIS <br /> �SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> XPAIRS: TYPE OF REPAIRS: 1146 L AM4E4 & <br /> --- CAICIA) r o <br /> d <br /> ,BANDONMENT/DESTRUCTION: METHOD TO BE USED: , <br /> .. C <br /> s <br /> do <br /> Z <br /> LOT PLAN: SHOW ON REVERSE SIDE ' <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> .CCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> OUNTY OFJOAQU THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> IGNED: 4CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY: DATE: 7 <br /> DDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> NSPECTION BY: DATE 3'u-7 INSPECTION BY; c 7- DATE <br /> H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> ISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY -OWNER — PINK—CONTRACTOR <br />