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r r <br />WELL/PUMP PERMIT <br />no <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 465.3420 <br />NONAEFUNDA FERMI 20 9 1 9553-7 97 F <br />INSPECTIONS <br />XPI ES FRgm DA ED <br />D IA,�LL <br />JOB ADDRESS y `'• <br />1 �^ <br />CITy21P <br />IJ %EAR <br />V Y I <br />,(�/I(�',rIy'/ j ,O <br />CROSS STREET ao ` �I W APN <br />ARCEL SIZE 77j�' <br />D USE APPLICATION Yr <br />OWNER NAMEUA9j<;;A!PHONE <br />OWNER ADDRE <br />CONTRACTOR <br />—}I----------- .---.._-_ 1/ I1 <br />Tk <br />MI. <br />CITY/STATE/ZIP <br />&115:ML-t —C13i <br />PHON <br />SUBCONTRACTOR ADDRESS • V 17—P <br />LICENSE C-57 C-61 D-09 <br />DOMESTIC WELL SAMPLING: General eral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (439:3) <br />INTENDED USE Domestic/Private 'gation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wallis) # of wells Soil BOring(s) "of boringsiF of borings <br />Geotechnical <br />Out -Of -Service Well Out-Of-Servi a W Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casino <br />(WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />e <br />■■■■■■■■!!■■■■■■I■l�R■►���■�1,■■■■\■■■■■■■■■■■■■ <br />N■■■■■■■■■■■IL!'J■■■��■■/illi ■\■■\■■■■■■■■■■■■ <br />■■■■■■■■■■/%■■■!\IIS■V■11■■■�[II/J■■I■!1\■■■■■■■■■■■ <br />l�■■\■■■■■■l1.1■!\!!R:■i■■■■■!■■■■■!■�!■■■■■■■■■■W <br />- IWI�o��j). � .. - � I - • <br />ENE <br />EHD 43-06 11/01/t6 <br />� ® ■ <br />WELL ;PUMP PERMIT <br />r� <br />N <br />1 <br />