Laserfiche WebLink
FOR VFICE USE: APPLICATION 04R WELL OR PUMP PERMIT PEIT NO. 7 y- 6o <br /> (Complete in Triplicate) Date Issued; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z- z z ri <br /> 1 <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: ' _ ��� Y �1' CENSUS TRACT: Ca-7- (40-r <br /> OWNERS NAME: jPHONE: <br /> ADDRESS: - �:ir�.+; r.t� CITY• <br /> CONTRACTOR'S NAME. � „,.;, « s2i LIOENSE # . p PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IARIGATION/LIVESTOCK/AGRICULTUiRAL WATER WELL L INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL f / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL,: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> _�✓e-� l�,_,�.; son 6-� f/!r-';.,�_ rf_.Y rn./-' !i�-D -� �,O�x-s� /=���� �1 <br /> REPAIRS: TYPE OF REPAIRS: >.[GL' <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> Ile <br /> PLOT PLAN: SHOW ON REVERSE SIDE �.,-C. <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: ,[L t ” - CON CTOR: <br /> - - - - -- - FOR DEPARTMENT USE ONLY - - - - - - <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: - <br /> PHASE II PHASE III FINAL <br /> INSPECTION 'BY: DATE INSPECTION BY: �_ DATE 7'3-7a <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />