Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 0 <br /> _ <br /> (Complete in Triplicate) Date Issued: Zv <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED / <br /> 4 € <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A P IT 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 J AQUIN LO HIRALTIi DISTR T. A <br /> JOB ADDRESS/LOCATION: � <br /> OWNER'S NAME: CENSUS TRACT: <br /> ADDRESS: PHONE: <br /> CONTRACTORS NAME• CITY: .S a <br /> ICENS��E�# PHONE: <br /> INTENDED USE: IND IVIDUAL.DOR W ER L /'� P4UBII�C_WA ELR WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK o d SEWER LINES -�'e7d PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER . -�- <br /> REPAIRS: TYPE OF REPAIRS: 1 <br /> H <br /> . s <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> s <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 TIME PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SA✓NNJJOOAQUIN$ AND T RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL`HEALTH DISTRICT. <br /> SIGNED: 1 CONTRACTOR: <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> LAI A. <br /> PHASE PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />