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A <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a Permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> � � 1 <br /> Joh Add,d j �• 4. a City x� Lot Size/Acreage <br /> �S. p - 3 33 SS' <br /> Owner's NameP Address /S �.� //v`��tr��- ^� =-— Phone <br /> Contractor_ "'-'"�� _—Address License N ro Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑', WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> — t.. - <br />