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SAN JOAQUIN LOPAL HEAITH DISTRICT ; <br /> FO.5��rOFFICE USE: 1601 E. Hazelton:Ave , -%Sto.ekton, ,Calif. i• <br /> Telephone::,-(209) 466467aj IE <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a k <br /> THIS PERMIT ,EXPIRES 1 YEAR.: QM DATE ,.ISSUED 'Date 3s'sued <br /> !�4f{,�,T,l(Complete.,In Triplicate) <br /> Application- is hereby A&Ved -Ioo''the San Joaquin local Ieal�th;-Dtatrict .for zpermit ta,'construct <br /> and/or.install the work herein described:, ^This .applicati:on is• made:4n,compliance,with San Joaquin <br /> County Ordinance No. '186 atiops th , n-,Joaquin,Loca Local,',, ict.r; I! <br /> JOB ADDRESS/LOCATION-"� !�rar 4�CENSUS`,-TRACT.!2_6s <br /> r r . <br /> .Owner's Name Phone <br /> Address <br /> Contractors Name .. 'License• ),207,9y Phone <br /> TYPE OF WORK (Check): NEW'WELL-�_7- -DEEPEN`/X—f -'RECONDITION'"/-7 DESTRUCTION-/7:- <br /> PUMP <br /> ESTRUCTION/7"PUMP INSTALLATION /_7 PUMP REPAIR / / PUMP;REPLAM T <br /> Other J% <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE /OTHER til <br /> PROPERTY LINE PRIVATE DOMESTIC WELL `` PUBLIC DOMESTIC WELL p <br /> INTENDED 'USE TYPE OF WELL , ,CONSTRUCTION SPECIFICATIONS a <br /> Industrial x Cable Tool Dia. of ; <br />