72-113 - Laserfiche WebLink

Home Browse Search

PLOT PLAN: SHOW ON REVERSE SIDE �• �> , � `�� ', "'rte ';.�a •-� > , r4+.�� ,.y .� �' j � • I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE COUNTY OF SAN JOAQUIN, AND THE RLES AND WI ATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. %�O ;T e 6"s- �e SIGNED: CONTRACTOR: c -e FOR DEPARTMENT USE ONLY PHASE I APPLICATION ACCEPTED BY: W_�, DATE: 3 i/ ,7 ADDITIONAL�COMMENTS: 1. PHASE, II- .: _� _ , a_s.. _ _ _ _ f' PHASE- III FINAL INSPECTION BY: DATE INSPECTION BY: DATE "Z/ -7Z,- E H 1426 'SAN JOA UQ IN LOCAL HEALTH DISTRICT 1/72 IM DISTRIBUTION: WHITE -HEALTH DISTRICT - YELLOW-PROPERTY'OWNER - PINK -CONTRACTOR - FOR OFFICE.USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. 3 (Complete in Triplicate) IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued: �_� -7 i .APPLICATION IS HEREBY MADE.TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM THE WORK STATED HEREON. THIS -MADE APPLICATION IS IN COMPLIANCE WITH COUNTY ORDINANCE NO. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. ot-7 ! .JOA ADDRESS/LOCATION: 3710 Mile S. Peltier 4001 E. 99 Frontage CENSUS S TRACT: -OWNER'S NAME: James Burnett PHONE: $.. ADDRESS: 22220 N. g Acam o Calif. 220 CITY: Lodi CONTRACTORS NAME: _Ptt gneQ Drillers _ LICENSE # 40107 PHONE: l 446§ INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /% PUBLIC -WATER WELL TEST / / WELL /_7 IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL% INDUSTRIAL WATER WELL / . CATHODIC PROTECTION WELL / % GEOPHYSICAL WELL ]Cl- OTHER / + ;NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK 125f SEWER LINES 1251 PIT PRIVY f N SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER, Q �i REPAIRS: TYPE OF REPAIRS: s ABANDONMENT/DESTRUCTION: METHOD TO BE USED: �r PLOT PLAN: SHOW ON REVERSE SIDE �• �> , � `�� ', "'rte ';.�a •-� > , r4+.�� ,.y .� �' j � • I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE COUNTY OF SAN JOAQUIN, AND THE RLES AND WI ATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. %�O ;T e 6"s- �e SIGNED: CONTRACTOR: c -e FOR DEPARTMENT USE ONLY PHASE I APPLICATION ACCEPTED BY: W_�, DATE: 3 i/ ,7 ADDITIONAL�COMMENTS: 1. PHASE, II- .: _� _ , a_s.. _ _ _ _ f' PHASE- III FINAL INSPECTION BY: DATE INSPECTION BY: DATE "Z/ -7Z,- E H 1426 'SAN JOA UQ IN LOCAL HEALTH DISTRICT 1/72 IM DISTRIBUTION: WHITE -HEALTH DISTRICT - YELLOW-PROPERTY'OWNER - PINK -CONTRACTOR -