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I FOR OFFICE USE: APPLICATION FOR' WELL OR PUMP PERMIT' <br /> PERMIT NO. Z-'`l'$ <br /> (Complete 'in.,Triplicate) Date Issued:, <br /> THIS PERMTT EXPIRES I YEAR FROM DATE ISSUED Y <br />' APPLICATION IS HEREBY MADE TO 'THE3 ' <br /> 5AN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT'TO <br /> THE WORK STATED HEREON. THIS APPLICATION IS PERFORM MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN-JOAQUIN LOCAL HEALTH DISTRICT. j{ <br /> JOB ADDRESS/LOCATION: <br /> OWNER'S NAME: CENSUS TRACT: <br /> ADDRESS: PHONE: 1 <br /> CONTRACTOR'S NAME: '. � CITY: L <br /> LICENSE �� � PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER <br /> •WELL / / -PUBLIC WATER WELL /' / TEST WELL /_ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INi?tTSTRIAL WATER WELL %/ <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 - f <br /> f <br /> i <br /> 7 <br /> ABANDONMENT/DESTRUCTION: METHOD TO $E USED: -" <br /> j <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT 1 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: f <br /> CONTRACTOR: <br /> i <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Et} <br /> � t <br /> APPLICATION ACCEPTED BY: 1 ` <br /> ADDITIONAL COMMENTS: DATE: -7 Z <br /> PHASE II <br /> P S II FINAL <br /> INSE HP14260N BY: ATEATE _ Z-- 72--- , <br /> SAN..-JOAQUIN 'LOCAL HEALTH DISTRICT f - 1/72 - 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK--CONTRACTOR <br />