Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR WELL OR. PUMP PERMIT <br /> PERMIT NO. <br /> (Complete in Triplicate) Date Issued.: <br /> THIS PERMITtEXT7-1fES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH D STRICT FOR FERMI O PERF <br /> Z-Z, <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE ORM <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> Pf Necpt- Cra_ cN 7- �v <br /> JOB ADDRESS/LOCATION: <br /> OWNER'S NAME: 6 CENSUS TRACT: <br /> ADDRESS; PHONE: <br /> CONTRACTOR'S NAME: �L4 CITY: <br /> �' -1FS[�N LICENSE # PHONE: N <br /> s� - 7Co <br /> INTENDED USE: - INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL E17 TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /% INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> i <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK OA SEWER LINES PIT PRIVY <br /> F SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> �n <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 RU S AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. + <br /> SIGNED: CONTRACTOR: <br /> f <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: DATE: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: - -DATE ,' <br /> E H 1426 - `/ -72,,— <br /> DISTRIBUTION: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT •. 1/72 1M i <br /> WHITE-HEALTH DISTRICT -,YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />