Laserfiche WebLink
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 3 5 3 <br /> (Complete in Triplicate) Date Issued: <br /> T L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED q ef70 7 <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: 9045 S. Endow Rd. CENSUS TRACT: <br /> OWNER'S NAME: Wade L+oyeday PHONE: 4647795 <br /> ADDRESS: 27 E. Main. St. CITY: Stockton <br /> CONTRACTOR'S NAME: J. A. Thalhamex Co. LICENSE 4272 303 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL J / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /—/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK55 ft-SEWER LINES 60 fP1T PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: Drill and case six inch well. Casing 120 ft. Drilling 140 ft. <br /> -9 <br /> D <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. <br /> SIGNED: CONTRACTOR: <br /> PHASE I FOR DEPARTME T USE ONLY <br /> APPLICATION ACCEPTED BY: .1� DATE: <br /> ADDITIONAL COMMENTS: <br /> A. <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: V11.� ,�R.yojDATE �� INSPECT10N BY: zc f DATE S J5,.j7,)__ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1./72 IM <br /> DISTRIBUTION. WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />