Laserfiche WebLink
,FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 72- Z' <br /> (Complete in Triplicate) Date Issued: r 7 z <br /> THIS PERMIT EXPIRES ] YEAR FROM DATE ISSUED <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 �OCAL HEALTH DISTRICT. <br /> On friva-fe 1^o-4 a7 HlrhpY �.y.r- <br /> V �Y <br /> JOB ADDRESS/LOCATION: Yfir l�� Mbar _ CENSUS TRACT: <br /> OWNER'S NAME: Robert Mc Lln PHONE: 948-9129 or 462- <br /> ADDRESS: 15' N "F" Street CITY: Stockton 1 '775 <br /> CONTRACTOR'S NAME: Walter G' No ck & Son Tnc.. LICENSE # 200 PHONE: 6 - ' <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL / I <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL %/ OTHER / <br /> NEW"-WELL: DISTANCE TO NEAREST: SEPTIC TANK t,@r SEWER LINES nI•€.p PIT PRIVY r()ne <br /> SEWAGE DISPOSAL FIELD none CESSPOOL TSEEPAGE PIT noneOTHER ' none <br /> 7 <br /> REPAIRS: TYPE OF REPAIRS: <br /> • � i <br /> i <br /> I <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> — <br /> s <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> i <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• Office Manage CONTRACTO Walter Go Noack & Son Inc <br /> FOR DEPARTMENT USE ONLY <br /> PHASE '.I � o <br /> ? ' ' DATE. f <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> 1 V . <br /> PHASE II v V- PHASE III FINAL <br /> I <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 'SAN-JOAQUIN LOCAL HEALTH DISTRICT 1/72 <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />