Laserfiche WebLink
1 <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. '7 2--673 <br /> (Complete in Triplicate) Date Issued: 6. z3. "7 z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> OC)3—(&0--0/ <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/LOCA Df SolCENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS; CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /� <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL Z INDUSTRIAL WATER WELL <br /> CATHODIC 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 /> REPAIRS TYPE OF REPAIRS." <br /> .I <br /> 4 ABANDONMENT/DESTRUCTIOM:.IMETHOD TO BE USED: <br /> {y <br /> PLOT PLAN: SHOW ON REVERSE SIDE U <br /> { <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 JO QUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCALIHEALTH DISTRICT. <br /> SIGNED: CONTRACTOR <br /> ---- Z FOR-DEPARTMENT-USE' ONLY'_ <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE IISPHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY:CJS • DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />