Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z 7-7 i <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - <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 /> JOB ADDRESS/LOCATION: ' ENSUS TRACT: <br /> OWNER'S NAME: (. PHONE: T G '.P, 7 -1 jP47 <br /> ADDRESS: CITY: r� <br /> CONTRACTOR'S NAME: CENSE #/ PHONE: <br /> 13 <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 I / GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE -TO NEAREST: SEPTIC TANK SEWER" LINES PIT PRIVY <br /> SEWAGE'DISPOSAL ,FIELD CESSPOOL SEEPAGE PIT OTHER <br /> k <br /> REPAIRS: TYPE OF REPAIRS: -� <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: CONTRACTOR: i <br /> I ' <br /> a <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE I x <br /> I APPLICATION ACCEPTED BY: ,c/f DATE: 4 Cf 72, <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II ► PHASE, III FINAL <br /> k INSPECTION BY: DATE _ INSPECTION BY: 444,.I. ATE 4'-I-1 <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />