Laserfiche WebLink
FOR OFFICE USE: <br /> APPLICATION FOR WELL OR PUMP PERMIT <br /> (Complete ,in Triplicate) PERMIT N0. � 3�7 <br /> y <br /> THIS PERMTT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7 y 7 L <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: <br /> k ,OWNER'S NAME: ----------- CENSUS TRACT: SSS <br /> ADDRESS: _11SrI PHONE: <br />! CONTRACTOR'S NAME: CITY: <br /> LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL 0 PUBLIC WATER <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ WINDUSTRIALEWATERLWELL/J <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK,190 <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGERP ;TNES OTHERT IVY N14pj <br /> REPAIRS: TYPE OF REPAIRS: <br /> Ih"t <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> Aft So <br /> PLOT PLAN: SHOW-ON REVERSE SIDE <br /> 4 <br /> T HEREBY CERTIFY THAT i HAVE PREPAREDNTHIS�APPLICATION'AND THAT THEAWORK WILL-BE DONE'IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, A r <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE STHE ORDINANCES OF THE <br /> AN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED <br /> 01_ � CONTRACTOR: <br /> PHASE.'I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: DATE: <br /> _q- <br /> rA <br /> Z_PHASE 11 <br /> PHASE III FINAL <br /> PECTION BY: DATE y" <br /> U26T D INSPECTION BY DATE ~ <br /> . SAN Jti— <br /> VI'T LOCAL HEALTH DIST UION: WHITE-HEALTH DISTRICTLOW-PROPERTY OWNER - PINK-CONTRACTOR 372 <br />