Laserfiche WebLink
p i1 <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued:L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9 O ] <br />! APPLICATION IS HEREBY MADE 0 THE SAN JOAQUIN LOCAL 'HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THISAPPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN- LOCAL„HEALTH DISTRICT. <br /> r JOB ADDRESS/LOCATION: l ii Sbaml (of- ci_r/2 (?� } ENSUS-TRACT: Q�3 - (020--Cur' <br /> OWNER'S NAME: pRG1rrJ1}O Si aiV =rr�" -- PHONE: (;, - '1p9p <br /> ADDRESS: It Jia eZ //b,971f ,_t/nr�F ,P Z Ao 9i-.2 VO CITY: <br /> CONTRACTOR'S NAME: eY� LICENSE # 1f;7,29i PHONE: ,36 F 2_?± <br /> _ C97,, Sc 0i _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /v/ INDUSTRIAL WATER WELL <br /> iC:ATHODIC-PROTECTION=WELL / GEOPHYSICAL WE'LL-/ /- - <br /> OTHER---NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 40t SEWER LINES 74. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> r� <br /> REPAIRS: TYPE OF REPAIRS: ,i__ t <br /> _ ,.. �°� <br /> ABANDONMENT/DESTRUCTION: fiMETHOD ;TO BE USED: w <br /> 4 Ud E �A ✓E Z k1:r.Y M L l4ew 6/17� <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 SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> i _ � <br /> SIGNED: CONTRACTOR: c <br /> L FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> r . <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: 4 DATE '"' INSPECTION BY: DA ! <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACT <br />