Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PlitSi FF.RMIT PERMIT N0. <br /> -7z--1 3 <br /> (Complete in Triplicate) Date Issued: 3-/.5 <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: ll 0St�<<r_�oti <br /> CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: T <br /> CONTRACT 'S AME: EaCENSE 4l Z.55977 PHONE: q.> <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /': PUBLIC WATER WELL / / TEST WELL /7 _ <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 /> Co <br /> N <br /> Z <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r <br /> .O <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 1 RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: A CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: �� DATE: S �y <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: Z!�z— DATE ?-;7-,7 7i <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />