Laserfiche WebLink
9 <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z--­7 � <br /> �. (Complete in Triplicate) Date Issued; 1_3-t- -7 <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 /> ,TOB ADDRESS/LOCATION: .,. �o ,CENSUS TRACT: # <br /> OWNER'S NAME: © ► si ��,�, c t c. PHONE: 4 ` � 'T <br /> ADDRESS: �t CITY: .> — <br /> CONTRACTOR'S NAME: LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL /TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL / J <br /> ,CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / j OTHER / / <br /> r ♦ JJ <br /> NEW WELL: DISTANSEWAGECEISPONEAREIELD .ST SE IC SS 0L S PAGERPIT ES OT IT PRI <br /> Y <br /> REPAIRS: TYPE OF REPAIRS: t <br /> CA..,.,� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE SED; <br /> a � <br /> 1 � <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> r <br /> I HEREBY T I HA PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN T;k, <br /> ACCORD CE WITH T PROVI ONN' LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY F S JOA : .ZN, HE .RU ES AND REGULATIONS OF THE SAN JO LOCAL DISTRICT. C� <br /> SIGNED: ! �� r.` CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY: DATE: <br /> 1- 32— <br /> i <br /> ADDITIONAL COMMENTS; <br /> PHASE II PHASE III FINAL <br /> r�--7Z-- <br /> INSPECTION BY: DATE _ INSPECTION BY DATE �� <br /> E H 142$ SAN JOAQUIN LOCAL HEALTH_DSTRICT 1/72 1M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />