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-v.e--` F; yam•--.-.�r,Q-, <br /> FOR�OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. � <br /> d <br /> p ((omplete in Triplicate} Date Issued <br /> HIS; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r � II <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> I THE WrORK STATED HEREON!! THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> s NO. A62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> ,SOB ADDRESS/LOCA N: CENSUS <br /> OWNERl'S NAME: PHONE: <br /> ADDRESS: <br /> �- <br /> CONT " TOR S N E: I ` CITY:—LICENSE 4� PHONE. <br /> INTENDED USE: IND <br /> IVIDUTAL DOMESTIC WATER WELL / PUBLIC WATER ..•.~ <br /> WELL/ / TEST -WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /;/ GEOPHYSICAL WELL %J OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK ✓' SEWER LINES f,PIT PRIVY ~ <br /> SEW GE DIS S FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: 1 <br /> I �. � ► i - yr <br /> ABANDONMENT/DESTRUCTION« • METROmp <br /> v f � i D TO BE USED: Q <br /> PLOT PPLAN: SHOW ON REVERSE SIDE r ) <br /> I HEREBY CERTIFY -THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL <br /> BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNT OF SAN OAQUIN, MIND T RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH STRICT <br /> SIGNED`:` t t CONTRACTOR: e ~� f° <br /> �R l <br /> PHASE <br /> FOR DEPAR NT USE ONLY Y <br /> Y <br /> ff i <br /> APPLIC{ATION ACCEPTED BY:af <br /> � _ DATE <br /> ADDITIONAL COMMENTS: <br /> Ir <br /> G I. <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE40 <br /> - . <br /> E :H 1426II - <br /> SAN-JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />