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FOR OFFICE USE: APPLICAT O`N'FOR WELL OR P"LrMi PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES l 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 LOCALHEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: (] l7 �V ✓N e R S �CENSU TRACT: <br /> OWNER'S NAME: PHONE: ffAX Z ._ <br /> ADDRESS: CI1R: <br /> CONTRAC AME: C ENS E # 2-5- 9.7 P HONE: <br /> INTENDED USE. INDIVIDUAL DOMESTIC WATER WELL f :�'—PUBLIG WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL, / 7—INDUSTRIAL WATER WELL f f <br /> CATHODIC PROTECTION WELL f / GEOPHYSICAL WELL L_f 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: <br /> 0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I REREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WTLL 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- CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL. COMMENTS: <br /> PHASE II PHASE III FINAL, <br /> INSPECTION BY; DATE INSPECTION BY: DATE - '--- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT I172 lit <br /> DISTRIBUTION: WHITE-REAI,TH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />