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s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601tE,_HAZELT'0N AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 <br /> f PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ! <br /> ' F I (Complete in Triplicate) <br /> Application is_heleby made,to the San Joaia it Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compltance.with an JbaQiri,County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �� + <br /> Job Address City me PM <br /> Owner's a dressy Q o� a r��Phone N <br /> Contractor Address g License No. a 10,2_3?3 F'hone 6L- <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ �iSYSTEM REPAIR ❑ OTHER ❑ [ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINESi DISPOSAL FLD. PROP. LINE <br /> AGRIt(LTIJRE WELL-nL- --OT•HER"WELL —"=-'----PITSISUMPS "- — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I I <br /> LJIndustrial ❑ Open Bottom C1Manteca Dia. of Well Excavation dia. of Well Casing 4 <br /> 11 1 <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 171 Public n Other FI Delta Depth of Grout.Seal= Type of-.Grout <br /> I I irrigationApprpx. Dept Fi E I Eastarn v� Surface Saal Installed by <br /> Repair Work= <br />