Laserfiche WebLink
FOR OFFICE USE: IF APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. L-L 3�L <br /> N I� (Complete in Triplicate) Date Issued: <br /> _ �v <br /> N/j ' 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. !ITHIS 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/LO TION: CENSUS TRACT: •' , <br /> OWNER'S NAME: 1 PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: r LICENSE # PHONE: { <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL`/ / PUBLIC WATEV WELL / / TEST WELL / F <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /✓/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL L/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> 9 <br /> REPAIRS: TYPE OF REPAIRS* <br /> 4 <br /> i A-W <br /> f <br /> ♦ r C4 <br /> _ b <br /> i- 7 a <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> S k <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I iiEREBY CERTIFY THA I HAVE PREPARED THff"APPLICATION_A W ZH&-TW'WORit`WILL BE"DQN_e rN <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: e <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED • I, Zvi <br /> DATE. L - 77 <br /> ADDITIONAL COMMENTS: 1M <br /> J <br /> PHASE II I P .I <br /> HASEII FINAL <br /> - n <br /> INSPECTION BY: `� I DATINSPECTION BY: /� �D <br /> E DATE 7_A2_ <br /> E H 1426 '� SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR � <br />