Laserfiche WebLink
t <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <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 /> il <br /> JOB ADDRESS/L C T�ON: e" CENSUS TRACT: F <br /> OWNER'S NAME: PHONE: T � <br /> ADDRESS: O ;_ CITY: <br /> CONTRACTORS NAME. LICENSE #14j- <br /> PHONE: K�i 1 - _L 12 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /27 PUBLIC WATER WELL / / TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_7 INDUSTRIAL WATER WELL /? <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK g,04AWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL S EPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: wle&_ ,AAiY� 6 Y R <br /> Bella o <br /> 4- <br /> ABANDONMENT/DESTRUCTION: <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 THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTTRICT. <br /> SIGNED: �, �,/YI�i//1 CONTRACTOR: /�+tm/ C <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE: ZZ—,;2-77, <br /> ADDITIONAL COMMENTS: <br /> PHASE II S I FINAL <br /> INSPECTION BY: DATE INSPEC ON B E 'je=�--F <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />