Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z,- -- 1 <br /> �I Date Issued: �{ 3 -7 <br /> (Comp3ete in :Triplicate) - - <br /> :�� T IS PERMIT EXPIRES 3 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. 3$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. �. <br /> CENSUS TRACT: 4 <br /> JOB ADDRESS/LOCATION: PHONE: <br /> OWNER-'S NAME: <br /> ADDRE'�S: I NSE 4� � PHONE: <br /> CONTRACTOR S NAME: <br /> INTENDED USE: IND VIDUAL .DOMESTIC• WATER WELL / PUBLIC WATER WELL TEST WELL 17 <br /> IRRIGATION/LIVESTOCK/AGRICULTURA WATER WELL //—INDUSTRIAL INDUSTRIAL WATER WELL L-1 <br /> CATHODIC PROTECTION WELL L_1 GEOPHYSICAL WELL / OTHER / <br /> NEWW1ELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY �_ _y <br /> SEWAGE DISPOSAL FIELD ­ CESSPOOL SEEPAGE PIT ..OTHER <br /> �Ilk <br /> REPAIRS: TYPE OF REPAIRS: <br /> 'll <br /> ABANAONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> F �1' <br /> PLO q PLAN: SHOW ON REVERSE SIDE <br /> y <br /> �HEREB"Y„CERTIFX THATy,I,�HAVE FPREPAREb 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 /> �p A¢ CONTRACTOR: <br /> SIGNED: <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I r <br /> lICATION <br /> DATE: <br /> APPACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> i <br /> k PRASE II <br /> PHASE III FINAL <br /> INSPECTION BY: �,�- DATE -�- 7Y <br /> INSPECTION BY: DATE mac/ <br /> ,i. - - 1172 V <br /> E HF 3426 SAN JOA UIN LOCAL HEALTH DISTRICT <br /> : DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />