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-YN1.• q..-._.._ S <br /> PERMIT NO. <br /> �}- APPLICATION FOR WELL OR PUMP PERMIT Date Issued: <br /> �'r L j <br /> FOR OFFICE US <br /> E: l 2 <br /> (Complete in Triplicate) I <br /> THI5 PERMIT EXPIRES I YEAR FROM DATE ISSUED q L[I 5 0 <br /> T TO <br /> APPLICATION <br /> IMADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR NTY ORDIINANGEERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION I5 MADE IN COMPLIANCE WITH C <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. c �1 <br /> CENSUS TRACT: J "-[ <br /> ,TOB ADDRESS/LOCATION: 17626 S: Campbell PHONE: 838-2 0 <br /> OWNER'S NAME: Joe A. Dubacher CITY: Escal.on <br /> ADDRESS: Ga a LICENSE # 2072 PHONE: 83 -7570 =5.. 00 y <br /> CONTRACTOR'S NAME: Jo n e rQ - _ 1 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /x/ PUBLIC WATER WELL Cl TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL L/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK <br /> 80 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: G <br /> 1 , <br /> F ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 0 <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> 114 <br /> THE WORK WILL <br /> k�JCHEiEZBY CERTIFY THAT I HAVE PREPARED THIS� APPLICATION AND THA <br /> IFORNIA THE ORDINANCESDOiOF THE <br /> k ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF 'T STATE OF CALIFORNIA, <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR; - <br /> SIGNED: <br /> C Z422- <br /> FOR DEPARTMENT USE ONLY } <br /> PHASE I i <br /> _ J - DATE: <br /> APPLICATION ACCEPTED BY: W <br /> ADDITIONAL COMMENTS- <br /> PHASE <br /> it PHASE III/FINAL <br /> PHASE II I <br /> r r <br /> `� / INSPECTION BY: l R- DATE 6_.=_�1- <br /> INSPECTION BY: r e (� DATE (�" -` 1/72 IM <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER .- PINK-CONTRACTOR <br />