Laserfiche WebLink
r <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. �7 Z -'qy <br /> - (Complete in Triplicate) Date Issued: y_c5.7z, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> abs- tea --o � <br /> APPLICATION IS HEREBY FADE TO THE'SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERF-ORi <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 DI TRI,ICT. <br /> /LOCATION: CENSUS TRACT: <br /> OWNER'S NAME: .6 ,,[,v}.r PHONE: <br /> ADDRESS: ZLO 1,0-/ <br /> CONTRACTOR'S N LICENSE # 7 23- PHONE: <br /> ,INTENDED USE: , INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> ' <br /> IRRIGATION/LIVESTOCK/AGRICULTURAFL WELL / / INDUSTRIAL WATER <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL L/ OTHER / <br /> NEW WELL: DISTANCE-TO NEAREST: SEPTIC TANK ) SEWER LINES -/PIT PRIVY &!1-V � <br /> SEWAGE DISPOSAL FIELD/ `CESSPflflL SEEPAGE PIT ? OTHER IJV <br /> � •s 4 , <br /> REPAIRS: TYPE OF REPAIRS: <br /> a <br /> F <br /> { <br /> ' ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> r <br /> y <br /> � t <br /> PLOT PLAN: SHOW ON REVERSESIDE <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 /> �~ 44 .FJi'/A <br /> SIGNED: CONTRACTOR: i�..�� <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY: <br /> DATE: l <br /> ADDITIONAL COMMENTS: <br /> PHASE II HASE7 III/ I L <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 1• SAN JOAQUIN LOCAL HEALTH DISTRICT M 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />