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d <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO2--1 5 5 <br /> (Complete in Triplicate) Date Issued: 3-z /-,7ri <br /> THIS PERMIT 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. <br /> JOB ADDRESS/LOCATION: 3 0 L9, -Van Allen Escalon CENSUS TRACT: <br /> OWNER'S NAME: C Richter - -- PHONE: <br /> ADDRESS; 8 ' Wrendale Way CITY: Sacramento <br /> CONTRACTORS NAME: John Panero LICENSE 71 1 Z724 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /x/ PUBLIC WATER WELL / f TEST WELL /-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL C/ OTHER f f <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 100'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER , <br /> REPAIRS: TYPE OF REPAIRS: <br /> F <br /> 00 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> t � <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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE. <br /> ADDITIONAL COMMENTS: V <br /> k - <br /> r <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: E kv DATE 3 `�'1. 7v- INSPECTION BY: - DATE '-�� �Z.--- <br /> i H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR H <br />