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V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-a�"31v <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - <br /> (Complete In Triplicate) <br /> Application le 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Isocal Health District. <br /> JOB ADDRESS/LOCATION Z CENSUS TRACT . ` <br /> Owner's Name Phone ' qj <br /> Address L' city , jw)E k) <br /> Contractor's Name o p License # (,^ Z Phone <br /> TYPE OF WORK (Check):' NEW WELLDEEPEN J?__: RECONDITION DESTRUCTION f-7 <br /> PUMP INST TION / / PUMP REPAIR /7 PUMP REPLACEMENT ' J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSS/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' :_ PUBLIC DOMESTIC WELL <br /> INTENDED USE , TYPE OF WELL {` CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable�looi-~ -- <br />