Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) bate Issued: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> j THE WORK S'T'ATED 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 /> i .TOB ADDRESS/LOCATION: 3 a ZJPd CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: _ J3 _2Z e.x! CITY: <br /> f CONTRACTOR'S NAME: r LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /i/ / PUBLIC WATER WELL /_/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDIfS—TRIAL WATER WELL <br /> CATIiODIC PROTECTION WELL / / � GEOPHYSICAL WELL / / OTHER /% <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> • v} <br /> oct <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <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, f <br /> F <br /> SIGNED: CONTRACTOR: <br /> - E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS. en DATE_ <br /> PHASE TI PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: X6� DATE ! - <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT - 3./72 3.M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />