Laserfiche WebLink
FOR OFFICE T'SE: APPLICATION,.FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in. Triplicate) Date Issued: ' <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> C 2,0`3 azp -(p3 <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 /> UO. 1862 AND RULES AND REGULATIONS OF THE 'SAN JOAQUIN LOCAL HEALP DISTRICT. t <br /> .JOB ADDRESS/LOCATI6N: S .6, . . CENSUS TRACT: <br /> DOWNER'S NAME-: /t� o� PHONE: <br /> ;ADDRESS: . D S J^a��� ^__....� CITY: �S'r4c, � _ <br /> ,CONTRACTOR'S NAME: S� u LICENSE i y3 A-9- PHONE: i4e.X 7 6 7 <br /> F <br /> .INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /? .PUBLIC WATER WELL /_/ TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /X-7_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL E/ 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 /> c- <br /> EPAIRS: <br /> Y�. r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <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 - JOAQU AND TH ULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r: <br /> APPLICATION ACCEPTED BY: DATE: ;�`7J <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: WHIT -HEALTH DISTRICT - YELLOW-PROPERTY 'OWNER - PINK-CONTRACTOR ' <br />