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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. _�L-! S S <br /> (Complete in Triplicate) Date Issued: 3-Z/- 7z� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> .PPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> 'HE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> 0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> OB ADDRESS/LOCATION: S. Jar_ Allen Escalon CENSUS TRACT: 51 <br /> ,WNER'S NAME: Ray mond C. EicY:tcr PHONE: <br /> DDRESS: 2718 �^7rendale i�av _ �� CITY: Sacramento <br /> ONTRACTOR S NAME: John Favero LICENSE # 120724 PHONE: t5c--(�yu -- 4C <br /> NTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /V PUBLIC WATER WELL f-1 TEST WELL L7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURX WATER WELL /7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL L/ GEOPHYSICAL WELL LJ OTHER /-7 <br /> EW WELL: DISTANCE TO NEAREST: SEPTIC TANK 10 O'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> .EPAIRS: TYPE OF REPAIRS: <br /> i <br /> cc <br /> c <br /> .BANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 3 <br /> LOT PLAN: SHOW ON REVERSE SIDE <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION *AND THAT THE WORK WILL BE DONE IN - <br /> CCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA ' THE ORDINANCES OF THE <br /> OUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> IGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY: DATE: <br /> DDITIONAL COMMENTS: <br /> z - - <br /> PHASES II 77rr PHASE III FINAL <br /> NSPECTION BY: t � DATE 3 77---- INSPECTION BY: -�� DATE '-/� �z~-- <br /> � H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />