Laserfiche WebLink
FOR OFF CE : "" APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. ,Z- -2 p z <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: Q G o7/? !� CENSUS TRACT: <br /> OWNER'S NAME: PHONE:, � <br /> ADDRESS: CITY. ` <br /> CONTRACTOR'S NAME: <br /> LICENSE <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /k— PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_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 CESSPOO SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 5�� q <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, THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: ��-- <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: ]ATE > S�� INSPECTION BY: DATE lll?3 <br /> d <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WH• TE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />