Laserfiche WebLink
FOR OFFICE USE: � APPLICATION FOR WELL OR PULP PERMIT PERMIT NO. -72 <br /> (Complete in Triplicate) Date Issued: <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 HEALTI1,1 DISTRICT. t <br /> JOB ADDRESS/LOCATION: CENSUS TRACT: �f <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: G r O <br /> PHONE: <br /> CONTRACTOR'S NAME: LICENSE # S?2S?-s?�O <br /> - <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL %/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' ei <br /> REPAIRS: TYPE OF REPAIRS: RE 91 L <br /> • .r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT.---,� <br /> SIGNED: _dQCONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: '� � - ~'� - DATE: - ----- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PEASE III FINAL <br /> INSPECTION BY: DATE 01EX 1. f DATE 11-7- <br /> E <br /> f-7'E H 1426 1 SAN JOA UIN LOCAL HEALTH DISTRICT_ 1172 <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR C <br /> m <br />