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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> 1601 E. HAZELTON AVE. , PHONE (209)488-3420
<br /> P".0 BOX 2009, STOCKTON. CA 98201
<br /> PERMIT RAM( r 1 YEAR ERN QTR I93[!Ba ,
<br /> (Complete in Triplicate)
<br /> Application is hereof esde,t:o Elan Joaquin County for a permit to construct and/or Install the work herein described. This
<br /> R"lientiie�nnttoo mod/ in ccaowli,btlo Ba.nce with Ban Joaquin County Ordinance 11o. Shy and 1e62 and the Rule/ and Reglations of Ban f
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<br /> r��License No. Rho
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<br /> PE OF WELLlPUMP: NEW WELL Q WELL REPLACEMENT E7 , DESTRUCTION Cl Out of 8orrice Well L1j
<br /> PUMP INSTALLATION E3 SYSTEM REPAIR 0 OTHER 0. Monitoring Yell D
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
<br /> INT&DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
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<br /> n Domewic/Private 0 Gnvd Pick 0 T►icy ,-,_Type of Cos Sp/pfkatkt►q d °r
<br /> III PlAft 1:1 Othw n Dslts Depth of Wan Sea _ ,.� Typo of arm
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<br /> WMI Daslwelbn 13 Wff"Dwftw Sealing Material A Depth
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