Laserfiche WebLink
'FOR.OF1FTC.E USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 2 <br /> (Complete in Triplicate) Date Issued: /- t- -7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> rzo--a <br /> APPLICATION IS HEREBY MADE TO .THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT T� PERFORM <br /> THE WORK STATED HEREON. MISAPPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 30B ADDRESS/LOCATION; ���� �a �� C,"7 o,"CENSUS TRACT: <br /> O�-:S NAME: 7 rrN,p o L PHONE: - 7 <br /> v U �a�► �. <br /> ADDRESS- �� � �Js9 z r+�C�T O�`%���'v CITY: <br /> CONTRACTOR'S NAME: JE A4 LICENSE �_'5 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL TEST WELL / O <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / f INDUSTRIAL' WATER WELL I l <br /> CATHODIC PROTECTION WELL / / 'GEOPHYSICAL 'WELL /�'%'_`OTHER `� / I . <br /> NEW WELL: D I STANCE TO NEAREST: SEPTIC TANK/4�SEWER LINES��� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/ '�ESSP00L SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> k r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> � r <br /> k <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAV EPARED THIS. APPLICATION,AND THAT THE<WORK WILL BE DONE IN <br /> ACCO PROVISI NS OF WS OF THE STATE'OF CALIFORNIA,. THE ORDINANCES OF THE <br /> COUNTY SAN JO LAIN; AND E fiT E AND� REGULATIONS OF THE SAN JOAQ LO DISTRICT. <br /> SIGNED: CONTRACTOR: '�`-- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: /� - <br /> ADDITIONAL COMMENTS: <br /> k <br /> PHASE II PHASE III/FINAL <br /> i <br /> INSPECTION BY: DATE INSPECTION BY: (A)_F- YoteDATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH.DISTRICT 1172 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />