Laserfiche WebLink
FOR OFFICE USE: . <br /> APPLICATION .FOR,.WELL OR PUMP PERMIT ERMIT FERMIT NO z p' <br /> (Complete' in' Date Issued: .', z �L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUYN 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 /> Z2-3 =z7'0-0 / <br /> �7 <br /> JOB ADDRESS/LOCATION: <br /> CENSUS TRACT;, ' <br /> OWNER'S NAME: PHONE:` <br /> ADDRESS: r. y CITY: <br /> CONTRACTOR'S NAME: �,; - LICENSE # PHONE: f <br /> INTENDED USE:.., INDIVIDUAL DOMESTIC WATER-WELL /—//.Z PUBLIC-WATER WELL / / TEST,WELL`/_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL_WATER WELL INDUSTRIAL WATER .WELL %/Y <br /> WCATHODIC 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 /> { <br /> k <br /> REPAIRS- TYPE OF.REPAIRS:-i <br /> ABANDONMENT/DESTRUCTION: METHOD TO 'BE-USED: <br /> 3 F F <br /> r , <br /> PLOT PLAN:\SHOW ON REVERSE SIDE <br /> + 1 <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 r <br /> COUNTY OF SANf,J($AQUIN, AND THE VLES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: �� CONTRACTOR: <br /> PHASE 'I <br /> FOR DEPARTMENT USE ONLY <br /> , <br /> 4 <br /> APPLICATION ACCEPTED BY: DATE: .` 7—)';�.gj <br /> ADDITIONAL COMMENTS: -- _ <br /> PHASE II PHASE III FINAL <br /> .E <br /> INSPECTION BY--v. DATE _ INSPECTION BY: DATE jG f 2 <br /> E H 1426 "SAN JOAQUYN LOCAL HEALTH DISTRICT 172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />