Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMA' PERMIT PERMIT NO. 7z' & 5 (- <br /> Tr' ,(, '(Complete in Triplicate) Date Issued: <br /> -,j HIS'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> -7 <br /> APPLICATION IS HEREBY MADE TO <br /> THE SAN JOAQUIN LOCALHEALTHDISTRICT 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 TH� SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �� v`'°2� CENSUS TRACT: 007- f'7 t7--(7 <br /> OWNER'S NAME: ! PHONE: —7 <br /> ADDRESS: CITY: -.�`� <br /> CONTRACTOR'S NAME: ''�'� l n LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / _/` TEST WELL'F/�/ . <br /> IRRIGATION/LIVESTOCK/AGRICULT L WATER WELL /—/_INDUSTRIAL WATER WELL / <br /> CATftODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL; DISTANCE TO NEAREST: SEPTIC TANK _ `SEWER LINES PIT PRIVY <br /> FI �f <br /> EWAGE DISP45 MELD CESSPOOL/ EEPAGE PIT '.s OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: } hl��' �j <br /> fj <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 ,J <br /> ACCORDANCE WITH THE PROVISIONS, QF�jHE LAWS OF THE�_STA_ TE.:OF CALIFORNIA, THE ORDINANCES OF THE 1 <br /> COUNTY OF SAN JOAQUIN, AND HE.�RtTLES AND`„REGULATIONSfOF THE SAN JOAQUIN LOCAL HEALTH ISTRICT. <br /> SIGNED• CONTRACTOR: <br /> —FOR' DEPARTMENT USE ONLY j <br /> PHASE I <br /> (,21 . <br /> APPLICATION ACCEPTED BY: / <br /> DATE: tv <br /> ADDITIONAL COMMENTS: _ ;, <br /> PHASE II f PHASE III FINAL <br /> IN BY: DATE _ IINSPECTION BY: �A DATE <br /> E H 1426 }. SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER --PINK-CONTRACTOR <br />