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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ZEMIT MIRES 1_MAR PROM, PATE 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 In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aztd Regulations of San <br /> Joaquin County Public Health Services. i <br /> Job Address� � /� _ City Toni Lot Size/Acreage 09 <br /> Owner' N -N Address ___ �� ,_ ,, ,, , , Phone <br /> Contractor 'S �Address� a tllhf �'License tV`o.' hon <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ ! <br /> Nonl.toring We1'1- ' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Q„ G7 <br /> DIST4NC TQ NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. r , POP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL i PTS/SUMPS <br /> t <br /> N7ENDfD USE ! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) <br /> 11 Indgstria � ❑ Open Bottom ❑ Manteca Dia-of Well Excavation Dia.of'Well Casing <br /> .Ftw U DOmestibPrivate Cl Gravel Pack ❑ Tracy T r ✓ <br /> ype of Casing � 5pe�ificatians <br /> Public t�; <br />