Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 L- 5.-3 � <br /> 1;2 04 4 Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5 5 y <br /> i <br /> APPLICATION IS HEREBY MADE 0 THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. TH APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGU IONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: , �,'„(/,��` CENSUS TRACT: <br /> OWNER'S NAME: PHONE: ' <br /> ADDRESS: .1, 1ri CITY: -� <br /> CONTRACTOR'S NAME: ' _ LICENSE # ] PHONE: S <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / /. PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL X INDUSTRIAL WATER WELL / / A <br /> CATHODIC PROTECTION WELL J / GEOPHYSICAL WELL / / OTHER <br /> I <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' ' `1 <br /> i <br /> REPAIRS: TYPE OF REPAIRS: E - <br /> e <br /> TABANDONMENT-/DESTRUCTION-:=-METHOD "TO BE-USED:' <br /> �1 R <br /> PLOT PLAN: .-,SHOW-,ON—REVERSE;'SIDE <br /> 8 , <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 /> I COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS 'OF THE SAN-JOAQUIN LOCAL HEALTH DISTRICT. <br /> t <br /> SIGNED .�_/'t- � CONTRACTOR: <br /> a� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> l <br /> i e <br /> APPLICATION ACCEPTED BY: C DATE: <br /> ADDITIONAL COMMENTS: x <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE ^ ` <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT l/72 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> e <br />