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SAN JOAQUIN .COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 1 P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 cotupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sana., <br /> Joaquin County Public Health Services. ` <br /> t J - h i <br /> q S) �'' ��� !�M City Lot Size/Acreage Q4�.� � <br /> Job Address _ <br /> Owner's Name <br /> r�ti'Y/ 0 t Address — -- Phone' <br /> Contractor h �r Address License No, d hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP.OtEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ } <br /> ' PUMP INSTALLATION ❑ —4, SYSTEM REPAIR"❑� OTHER ❑- 1 Monitoring Well €� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` DISPOSAL FLD. � PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS f <br /> INTENDED USE-. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i_1 Industrial ❑ Open Bottom [IManteca Dia. of Well Excavation ' Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I i'1 Public ''^ taOther (1 Delta '� Depthi df-Giout"Seal-� <br />