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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209),.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA? PERMIT Permit No. �7,2 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County .-Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1' <br /> JOB ADDRESS/LOCATION O /V. <br /> /ten, �e. CENSUS TRACT <br /> I� <br /> Owner's Name r /Z P Phone <br /> Address <br /> Cit <br /> . y <br /> p Contractors Name License �f Phon� - Z <br /> TYPE OF WORK (Check) : NEW WELL:'/ "/ DEEPEN /_% RECONDITION J / DESTRUCTION /- <br /> PUMP INSTILATION / PUMP REPAIR / / * PUMP REPLACEMENT /-7 <br /> ti i Other.. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> :SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial ,/Cable Tov1 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ° t� <br /> k <br /> Domestic/public Driven ' Gauge ,of-*Casing , <br />