Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z-?-- D <br /> i <br /> (Complete in Triplicate) Date Issued: -:Z- 7 <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 LSAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: <br /> OWNER'S NAME: L,-,i PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: Av Aw &23 LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL /—/ PUBLIC WATER WELL f_1 TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / 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 /> 'a <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ , - INSPECTION BY: DATE <br /> E H 1426 . SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />