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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 7- 3 S!) <br /> 77- -;2-7P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedLL3'-77 <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 :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION � � . CENSUS TRACT <br /> Owner's Name Phone <br /> � <br /> Address City <br /> Contractor's Name LicensePhone f, ~ <br /> TYPE OF WORK (Check): NEW WELL, /_W- DEEPEN '/_7 RECONDITION /7 DESTRUCTION % <br />