Laserfiche WebLink
FOR OFFICE USE: APPLICA ON FOR WELL OR DUMP PERMIT PERMIT NO. - a1v <br /> (Complete in Triplicate) Date Issued: Z ! <br /> THIS PERMIT EXPIRES I 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 /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. �y <br /> t 'ZZS Aely l : 60:5-- 240-y. / <br /> :JOB ADDRESS/LOCA ON: Lv 4�,cc�-�+ .�yi+ `Js- �.t.�-tA� CENSUS TRACT: <br /> OWNER'S NAME: 0 N C PHONE: 1-6, 3 <br /> ADDRESS: • CITY: C a oC <br /> CONTRACTOR'S N e LICENSE 4�J PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER_ WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /U INDUSTRIAL WATER WELL / / <br /> i CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> % _ <br /> j NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> f REPAIRS: TYPE OF REPAIRS: <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 THEiWORK WILL BE DONE IN <br /> i 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 /> 1 <br /> 1 <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 "2 7� <br /> E H 1426 `"SAN JOAQUIN LOCAL HEALTH DI_STRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />