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-1.14‘.A Gv, [I.- [6 (>t,‘" <br />WELL/PUMP PERMIT <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />DOMESTIC WELL SAMPLING: IllGeneral Mineral/Coliform Bacteria (4391)11IDibromochloropropane (4392) EJArsenic (4393) <br />TYPE OF WORK E New Well Li Replacement Well ['Well Alteration/Modification ['Other <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTor4 AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT cALL120,9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />JOB ADDRESS k100 NI —I'LL ly 0/• , <br />D CROSS STREET ULa, C-04 • APN ,Rops —d 41-0 —if o PARCEL SIZE tAS---LAND USE APPLICATION # <br />AA. 7 e biAiN Sr <br />CITY/STATE/ZI <br />CONTRACTOR <br />SUBCONTRACTOR r‘Nhi PHONE iryil <br />OWNER NAME <br />OWNER ADDRESS <br />tI <br />.eatisummimatanitzra <br />L{o012-mans, <br />CONTRACTOR ADDRESS 212,0 WI CO <br />P40 <br />"no Titr, PHONEM 931 .3ai <br />CITY/STATE/ZIP 9.3-Di-s" <br />EXPIRATION DATE1 5/17 <br />CITY/ZIP <br />C-57 D C -6 1 D-09 0 Other NUMBER LICENSE <br />INTENDED USE Domestic/Private Li Irrigation/Agricultural D Industrial ['Water Quality Monitoring 0 Soil Sampling/Characterization <br />El Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />lenitoring Well(s) <br />ut-Of-Service Well <br /># of wells ['Soil Boring(s) <br />Li Out-Of-Service Well Renewal <br />Li New Pump Li Pump Replacement Li Pump Repair <br />LI Geotechnical <br />['Cross-Connection Repair <br />['Raise Well Casing <br /># of borings <br />EHD 43-06 8/01/16 <br />. <br />WELL /PUMP PERMIT <br />EPi RTMENT SE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS Lk- Q(-) ZD (7-0 V-\ <br />AreaC4 j Employee ID#C5C-Ofl— <br />LI SPECIAL Well Permit <br />LI WAIVER Received <br />Constructed We!! Depth ft <br />.5c-e Carr:9+ <br />Date <br />Date <br />Date <br />Date <br />•••=1m..." •••••• <br />\./ kr <br />C.) w <br />PE <br />Codes <br />SC <br />Inf <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />4"11%6Id a 7S,-__ I 3 70 A-M. (lc' 121P-Mi (cK00-70/09 :SSMICICIV 311S # of borings