Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date ue,� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 f <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. '? <br /> JOB ADDRESS/LOC TION: • CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S N E: LICENSE # ` <3 7 PHONE- 4�4 4 .237_ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL Z/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER _ f_7 <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: f" <br /> I <br /> 11 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: "' O <br /> 4 <br /> ' s#i <br /> PLOT PLAN: SHOW ON REVERSE SIDE f <br /> F <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 DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: C ti / _ _ DATE: z/9 <br /> �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> I INSPECTION BY: N DATE _ INSPECTION BY: n&, DATE <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR C <br />