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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUN77 PUBLIC HRALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> 445 N SAN JOAQUIN, PHONE !209)468-3420
<br /> P 0 BOE 2009, STOCKTON, CA 95201
<br /> PERMIT RXPIRRS 1 Y AR FROM_�ATfi ISSUhD
<br /> (Complete In Triplicate)
<br /> ApPllntlon 1. N•nby ted. b 8" Jo.Rule County for • p.ralt m conaruct .M/or 1n.ull tM wrL Mrrin de.erlb•d. TTI•
<br /> Josilt•tfoR 1. •ad• in oattpll.00• with D•p Ja•quln Countl Dlel lune• Ro, $19 .M 1062 .M tM P41 . .00 Re`ul•tl... of S.n
<br /> Jeyul. Cam 1. Nlbll e1�0OW1,tS 0 with 5 /ol
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<br /> TYPE Of—WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of S.rvle• Y.11
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<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NooltorinE Voll ❑
<br /> MSTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO_- PROP LINE _
<br /> 4 FOUNDATION AGRICULTURE WELL _- OTHER WELL PITSISUMPS _
<br /> SINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
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<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI TION UESI RUCTION I i IN.rp,C%"I.pMm,Po A pAKe wrr.r s
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<br /> PxG-TREATMENT Pty.0 kA.,l.od of Dl.vrl•w
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<br /> LEACNWG Low 0 No.S Lwgd,of mo.
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<br /> �.Er OR DEPARTMENT Unit ONLY
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