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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z_-(4' <br /> (Complete 'in Triplicate) ; , Date Issued: 3. z_ 6 Zv <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 /> 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: s <br /> ' <br /> OWNER'S NAME: <br /> ------ CENSUS PHONE. <br /> ADDRESS: _v7 0 _� .' .2°s,.„m.�,� ppan +, CITY: <br /> ,. <br /> CONTRACTOR'S NAME: � P�_, nom,..} LICENSE # &.4�7 1— PHONE: - <br /> 17 <br /> r <br /> INTENDED USE: INDIVIDUAL:DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL-WATER WELL / /. INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL f-/' OTHER /_7 <br /> NEW WELL: DISTANCE NEAREST: SEPT, K _ SEWER LINES--:--, PIT PR <br /> SEWAGE DISPO IELD , CESSP0 PAGE PIT OTHER--- <br /> REPAIRS: TYPE OF REPAIRS: <br /> vl <br /> A � <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE ' <br /> 3 <br /> I HEREBY CERTIFY THAT I 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 /> 4 r <br /> SIGNED: CONTRACTOR: <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I .� <br /> APPLICATION ACCEPTED BY: _ �� � DATE: Z, <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE y' -- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT. 1/72 1M <br /> .DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />