Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> µ (Complete in Triplicate) Date Issued: Z_:/-_72— <br /> HIS 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 S'T'ATED 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 /> r <br /> JOB ADDRESS/LOCA ON: CENSUS TRACT: <br /> OWNER'S NAME: e5 PHONE: <br /> ADDRESS: CITY: {�C. <br /> CONTRACTOR'S NAME: ? LICENSE #� PHONE: <br /> S _ <br /> INTENDED USE: INDIVIDUAL-DOMESTIC WATER WELL PUBLIC• WATER WELL / / TEST WELL /_ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_/_INDUSTRIAL WATER WELL / f_ <br /> CATHODIC PROTECTION WELL-/—/ GEOPHYSICAL WELrL / / OTHER J / <br /> ! I <br /> NEW WELL: DISTANCE TO;NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOO 7SEEEPAGE PIT —OTHER - <br /> REPAIRS: <br /> THER -REPAIRS: TYPE OF REPAIRS: <br /> .y� �. • •. .IJ��y, r esu/c .�► �, i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: ' <br /> 711% . <br /> T Q <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> j <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, Tilt ORDINANCES_ OF THE <br /> COUNTY OF SAN OAQUIN, THE RULES AND REGULATIONS OF THE SAN JOAQUIN WCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A ' <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL ,COMMENTS: _.._ .._ <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ _ 1&S &TION BY: N DATE <br /> E H 1426 SAN' JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: ITE-AEALTH DISTRICT - YELLOW-PROPERTY„OWNER - PINK--CONTRACTOR <br />