Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMA' PERMIT PERMIT N0. 7 Z Sa _ <br /> (Complete in Triplicate) Date Issued: <br /> TAHIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY <br /> 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: CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: Q r`� CITY: <br /> CONTRACTOR'S NAME: aay,/ LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /% PUBLIC WATER WELL / / TEST WELL /7 i <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /%_INDUSTRIAL WATER WELL <br /> / % <br /> CATHODIC PROTECTION WELL / 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 <br /> REPAIRS: TYPE OF REPAIRS: <br /> h <br /> Li <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: �/1 <br /> .wI <br /> )e21Coe <br /> 01 <br /> r <br /> w Azz <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 /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: DATE: 'e"9 P,2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY:41gl <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1172 1M �- <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR / Z <br />