Laserfiche WebLink
11 1:'f IES <br /> FOR OFFICE USE: z,APPI,ICAT1ON7 ELL OR PUMP PERMIT PERMIT N0. __�_5 5 , <br /> (Complete Triplicate) Date Issued: 7_ . <br /> HISEERMI%TIR YEAR FROM DATE ISSUED <br /> SAN JC)Ai4U1N LOCAL <br /> APPLICATION IS HEREBY MADE TP,ETHEf,SAN:19O QU7-N LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK -STATED HEREON. FTHIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CI.o <br /> JOB R' RLh ` <br /> CENSUS •�Pb7--f oo—f2 _a <br /> OWNER'S NAMEPHONE: <br /> ADDRESS: 10 4L f CITY: <br /> CONTRACTOR'S NAME: LICENSE 4if p PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL f / PUBLIC WATER WELL / fTES I�WELL- °/ "• ~ ` <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSTRIAL WATER WELL f / <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER' LINE5 PIT PRIVY <br /> SEWAGE DI OSAL FIELD CESSPO L/SEEPAGE PITS TPR <br /> REPAIRS: TYPE O REPAIRS: Y ,yam <br /> ado K�DZ_4C21 � . <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED, c r ' <br /> 4 <br /> PLOT PLAN: SHOW ON REVERSE SIDE -r <br /> r. <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 OAQUIN, AND TU RULES AND REGULATIONS OF THE SAN JOALOCAL HEAL ISTRICT. <br /> SIGNED: r �. CONTRACTOR:; .iCk <br /> FOR IDEPAR *ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ate.[ DATE: t <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE _ iINSPECTION BY: DATE 'f� ' <br /> E H 1425 SAN JOAQUIN LOCAL`HEALTH DISTRICT 1/72 im <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />