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FOR, OFFI�;E USE: j APPLICATION FOR WELL OR PUMP PERMIT <br /> \ PERPlIT N0, <br /> (CORIPlete 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: l (p5 � � CENSUS TP.ACT- <br /> 01,7gER'S NAME: aOZP}fONE: <br /> ADDRESS; � <br /> CONTRACTOR'S NAME: CITY: �••. . <br /> a. LICENSE # (61�-�3 PHONE: �'L S <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /V7-K PUBLIC WATER WELI. /_/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> :ATHODIC PROTECTION WELL / / GEOPHYSICAL OTHER /% <br /> 4EW WELL: DISTANCE TO N SEPTNK SEWFFRLIN PIT`R1�IVY <br /> SEWAGE DISPOSAL FIELD �ICTA <br /> SSPOOL S W PIT OTHER <br /> :EPAIRS: TYPE OF REPAIRS., <br /> ti <br /> BANDONMENT/DESTRUCTION: MET OD TO BE USED: <br /> S <br /> o <br /> 7 <br /> LCT PLAN: SHOW ON REVERSE SIDE <br /> HER Y CERTIFY THAT HAV PREPARED THIS APPLICATION AND THAT THE WORK ',,TILL BE DONE IN <br /> :CO ANCE WITH THE P VISIONS OF HE LAWS OF THE STATE OF CALIFORN <br /> IA, THE ORDINANCES OF THE <br /> )UNT OF SAN .JOA UI THE R LES REGULATIONS OF THE SAN JOA UIN LOC H DISTRICT. <br /> IGNED: CONTRACTOR: <br /> }ASE FOR DEPARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY: DATE, Z— Z1 <br /> ,DITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> SPECTION BY: LTJ ` DATE INSPECTION BY C�k// DATE 2--2 - /1a_ <br /> H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> STRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />