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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;/z 91cj ' <br /> Z7-�g p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 77 <br /> y <br /> (Complete In Triplicate ) <br /> Application is hereby made tothe 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 andithe Rules and Regulations of the San Joaquin Local Health District. a <br /> JOB ADDRESS/LOCATION /_jO /r// /C,,,. �vQ� CENSUS TRACT <br /> Owner's NameC' F <br /> ze Phone <br /> Address / <br /> zzzz City <br /> Contractor's Name License hone <br /> .. <br /> l <br /> TYPE OF WORK (Check) : NEW WELL /g DEEPEN '/—/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION b/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ZjC SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDZJ'f`CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE"= <br />