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FOR OFFICE USE: CAPPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued:- L <br /> IT EXPIRES 1 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 LOCAL. HEALTH DISTRICT. 20 —[-To <br /> �la <br /> West side cf Van Allen just l'�1pS R 8�E Sec. 11 <br /> JOB ADDRESS/LOCATION: North. of Mari_Dosa CENSUS TRACT: <br /> OWNER'S NAME: D.L. D kx_hoorn PHONE: 838-2922 <br /> ADDRESS: 1 0 b 55 S. Van A.11en r CITY: Escalon <br /> CONTRACTOR'S NAME: Tr;hn L. .. Panero . Jr„ LICENSE #120724 PHONE: 838t--7570 -5 00 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL 20 INDUSTRIAL WATER WELL El- <br /> CATHODIC PROTECTION WELL / ./ GEOPHYSICAL WELL/ / OTHER <br /> 14" well 1 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 7 5"SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT' OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br />�I I <br /> i <br /> i <br /> PLOT PIAN: 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 /> k 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY( * f sS_ DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: N14) DATE INSPECTION BY: DATENa <br /> E H 1426 1 . SAN JOA UIN LOCAL HEALTH DISTRIC 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> G <br />