Laserfiche WebLink
FOR OFFICE USE: A LICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7Z - <br /> (, 3 <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 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 /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: /,°L- cD S �ia. - .,ya CENSUS TRACT: <br /> 'f <br /> OWNER'S NAME: �� PHONE: <br /> e <br /> ADDRESS: a e.r°. CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: _0 2-7 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL /_ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> -ATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK jov - SEWER LINES Ga ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Z,�2+ CESSPOOL SEEPAGE PIT;Xa_ OTHER <br /> 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 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 RUL S CREGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: Ozv YuA CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: - <br /> ADDITIONAL COMMENTS: <br /> Y <br /> �� <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR �} ' <br />