Laserfiche WebLink
1 <br /> OFFICE USE <br /> FOR OFFICE N FOR WELL OR PUMP PERMIT PERMIT NO. 7-- <br /> (Complete <br /> (Complete in Triplicate) Date Issued: 8"7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Y <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/LOCATIO o CENSUS_ TRACT: <br /> OWNER'S NAME: PHONE. <br /> ADDRESS: 4 CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL I&, PUBLIC WATER WELL /_/ TEST WELL ___ t <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / LL /INDUSTRIAL WATER WE / <br /> / # <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: <br /> k 1j <br /> ,9 <br /> J <br /> i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <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 5AN J AQUI AND T AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> R TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: _ <br /> ADDITIONAL COMMENTS: 2� <br /> PHASE II FINAL <br /> INSPECTION BY: DATE INSPECTION BY- DATE <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRI 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -CONTRACTOR <br />