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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTOH AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> MIT WIRES 1 YEAR FROM D TE ED <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 trade 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 /> City Lot Size/Acreage <br /> Job Address <br /> jv IAdress � �A 17/cd _ Phone <br /> Owner's Name - <br /> � ® � No c� <br /> Contractor /Cs� Address License hone <br /> TYPE OF WELL/PUMP: NEW WELL C�,, WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of ovice Well ❑ <br /> a Monitnoring Well ❑ <br /> t PUMP INSTALLATION El `, SYSTEM REPAIR C OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION • AGpICULTURE WELL OTHER WELL PITS/SUMPS r <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [_} industrial � Ci Open Bottom .r' ❑ MantecaDia. of Well Excavation <br /> Dia. of Well Casing <br /> IType of Casing Specifications <br /> Cl Domestic/Private L1 Gravel Pack ❑ Tracy r 9 <br /> I'I Public of Grout <br /> I:) Other ( <br /> � �_ Delta _ ; Depth of Grout Seal � <br /> I I Irrigation { `� -App ox. Depth' 11 Eastern Surface Seal Installed by <br /> Repair Work Done,-L7'+ Type of.-Pump H.P. State Work Done <br /> Well Destruction 0 Well: <br />