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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> p Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described. This application is <br /> I� RR Y ,q Re RR <br />' made in compliance with San Joaquin Codnty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. rA-ptJ *k O(( I/QO"GSr ] <br /> Job Address Zn -3 l �. {.�.�D 21 Q®� City Lot Size PM <br /> ,� /3 �O;.CXR &J_ -VVuV K..6y� M& <br /> Owner's Name �� t 49)71C l<- Address ���� �� 1'1�b4 pin Phone -� <br /> �r1 i w <br /> Contractor's Name 111hn License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION'❑rSYSTEM REPAIR'❑ ^r"""-"^"— - OTHER-El — <br /> DISTANCE <br /> THER❑ '-^•"DISTANCE TO NEAREST: SEPTIC TANK _'�70 SEWER LINES DISPOSAL FLD. PROP. LINBiP0- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �► i <br /> ❑ Industrial ($.Open Bottom � 1-1 Manteca ilia. of Well Excavatio Dia. of Well Casing <br /> 7: <br />