Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 72-- 3 5 C <br /> (Complete in Triplicate) Date Issued: -.5-/'2�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED c7�t 7 p <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: Cam b ell CENSUS TRACT: <br /> OWNER'S NAME: o-8 e A Dp b a c he r PHONE f3 <br /> ADDRESS: same CITY: Escalon <br /> CONTRACTOR'S NAME: John ,Fane ro LICENSE #120724 PHONE: `"J 00 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /x/ PUBLIC WATER WELL / / TEST WELL /� <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL' WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> - f <br /> E NEW WELL: DISTANCE TO .NEAREST: SEPTIC TANK 7 SEWER,LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPQOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: i <br /> 3 <br /> .6 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: y `* <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> f <br /> r7 % . <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 J04QUIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR• " <br /> SIGNED: <br /> . <br /> t <br /> t ' <br /> FOR DEP AR ANT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: _. G _ tJ, DATE: 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> � n <br /> INSPECTION BY: DATE _ INSPECTION BY; t tl DATE <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> i DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />