Laserfiche WebLink
FOR OMCE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete 'in Triplicate) Date Issued: 3-1 - 7 <br /> THIS PERMIT EXPIRES' I 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. p <br /> JOB ADDRESS/LOCATION: ,t F , � k mom✓. CENSUS TRACT. <br /> OWNER'S NAME- -4)"12 PHONE: <br /> ADDRESS: cr S t CITY: <br /> CONTRACTOR'S NAME: `' 3. LICENSE # !G?.q 7.3 PHONE: <br /> 141- <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER W LL f% PUBLIC WATER WELL. /—/ TEST WELL / J <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL—/_/ OTHER <br /> NEW WELL: DISTANCE TO NEARES SEPTIC TANKWER LINES PIT PRI <br /> SEWAGE D P05AL FIELD SSPOOL SEEPAG OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br />` O <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED- . <br /> 5 <br /> PLOT PLAN: SHOW ON REVERSE SIDE # <br /> 4 <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 RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> s <br /> SIGNED: L. CONTRACTOR: �a <br /> r <br /> ry <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: C_% DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE IT PHASE III FINAL// <br /> INSPECTION BY: NlR DATE; INSPECTION BY: DATE <br /> E H 1426 "" ..T ' SAN JOAQUIN LOCAL HEALTH DI_STRI 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />