Laserfiche WebLink
1 �f SYL)-M `raAA 04-50"` <br /> FOR OFFICE.,USE: f APPLICATION_FOR WELL OR. PUMP PERMIT PERMIT N0. '7 2-� . <br /> .•(Compl.ete,nin Triplicate) Date Issued: Z2, 77-- <br /> S PERMIT EXPIRES '1 YEAR FROM DATE ISSUED <br /> Ic-iq In, <br /> APPLICATION IS HEREBY MADE TO`tHi"'$AN''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 OFTHESAN-JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: ' 19765 S•.Sutlif£:Ral.�Oakdale CENSUS TRACT: s` <br /> OWNER'S NAME: C: L. Wilson &.Hollis Patrick PHONE: 847-2304 <br /> ADDRESS: 117 East ;"F" Street I 'Oakdale " y�'°T " ' CITY: Oakdale <br /> CONTRACTOR'S NAME: William De -Centet -LICENSE # 236051 PHONE: 847-2304 -- <br /> INTENDED USE: INDIVIDUAL'.DOME ST ICWATER .WELL;/�UBLIC,WATER-°WELL-/77-TEST WELL ./ / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL/ / OTHER <br /> �. _. n <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK Sb SEWER LINES 50 PIT PRIVY NQN i ` <br /> SEWAGE DISPOSAL FIELD _221_ CESSPOOL TSEEPAGE PIT /OCA OTHER Ncdj <br /> !1(5 TA u4Tr o 1f <br />' REPAIRS: TYPE OF REPAIRS; - <br /> Z <br /> �x <br /> -CA <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: NLOJ 11U57/-) �-T7r0ti <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 RUL AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> y <br /> SIGNED: CONTRACTOR: William D. Center <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> .APPLICATION ACCEPTED BY: DATE: <br /> .ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> r r No-F CzRvuT-F—�'D <br /> 'INSPECTION BY: PA I p DATE INSPECTION BY: _ 0 DATE -. <br /> E H 1426 TO' 0RbiMArJ.C-f__ - SAN-JOAQUIN"LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />