Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. �� 5 <br /> (Complete, in Triplicate) Date Issued: .5-1--72- <br /> THS <br /> -/--7ZTHS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> v <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. 22__S 0&0- <br /> JOB <br /> ma JOB ADDRESS/LOCATION: Northeast corner,,-of .First & Walnut CENSUS TRACT <br /> OWNER'S NAME: Ronald Cohagen PHONE: 838-3019 <br /> ADDRESS: --- CITY: Escalon <br /> CONTRACTOR'S NAME: o-b- PA, a M LICENSE #120724 PHONE: 838-7570 887:5400 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /x/ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL f_1 INDIfS—TRIAL WATER WELL f_1 <br /> CATHODIC PROTECTION WELL / j GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER'City sewerage system <br /> REPAIRS: TYPE OF REPAIRS: <br /> 14� <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 'C <br /> k r�' <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 REG6LATIO_NS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: <br /> k k�---CON-TRACTOR <br /> 7 <br /> FOR DEPARTMEN USE 'ONLY <br />� PHASE I <br /> APPLICATION ACCEPTED BY: C1 f . DATE: a" <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: tiC3 DATE ,j -t =ZZ INSPECTION BY: Q DATE -ZG 7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> I DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> ` . .40 <br />