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If different from Owner <br />INTENDED USE 7 Domestic/Private I Irrigation/Agricultural I7 Industrial 0 Water Quality Monitoring <br />7 Public Water System <br />Water System Name <br />TYPE OF WORK I New Well ii Replacement Well Well AlterationiModification 11 Other <br />Date Li FA? / <br />DEPARTMENT USE ONLY <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />11 4 11 IC' <br />Area Employee ID# <br />1] SPECIAL Well Permit <br />ii WAIVER Received <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Cfr, dr) S. (eit 1-,y( v arra°, 1,-P1( : i 1 .) 4 c , <br />CROSS STREET 10 14 4 y APN O il 73 ,;..)il ? PARCEL SIZE ,, f')i, LAND USE APPLICATION # <br />OWNER NAME "jiiii4 <br />OWNER ADDRESS '5 )N 9, }-e al^ CP( c' k IZ A, CR Y/STATE/ZIP L. Zia, , q s - ..4c) <br />CONTRACTOR it)6 es 77k Pm e'f -1'14,1 Te/A ri; ("rf S('-i^v• ,/ ,-5 -1-atC PHONE 2e7qA 645 / iy9",7 <br />CONTRACTOR ADDRESS 44 /3 -6-y1 , e t pit'eXC -/4/47' 5th'irq-cayis-rATEizip P.--)4-7A,--7-c....> , r /1 <br />SUBCONTRACTOR/CONSULTANT INH r- - 43., I 1 ivi Co <br />SUBCONTRACTOR/CONSULTANT ADDRESS j.,411)0 j4‘ lin et' <br />F <br />i .. yrrvISTArE/ZIP IA/I el 41) CI 5: Gtr u 1 _ <br /> <br />NUMBER 4/ 121;' C., CO C EXPIRATION DATE .."-S- /f g i i 2- i <br />II' CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) 7 Arsenic (4393) <br /> PaymENT <br />RE CEivg." <br /> PR 08 2021 SAN Jo <br /> HEAEI <br />Acki/N <br />NTHIRD°N-1"EVTAULN71/ EPARNENT <br />Date <br />Date <br />Date 4/ 19128'0 Constructed Well Depth ft <br />_ ,t - • <br />PE <br />Codes <br />SC <br />Info <br />ReceivedCt(.....ci:Lc01.--7 <br />ash <br />Amount <br />Remitted Date i <br />Permit/ <br />Request # Invoice # Well ID# <br />1-137() IS-0 alY, --- 3-7.a , F oe It I ril <br />geovipe <br />Lik) Li 101 15 <br />INC-57 <br />BILLING PARTY: <br />LICENSE - C-61 - 0-09 <br />o OWNER <br />- Other <br /> PHONE <br />PHONE <br />DA <br /><a <br />4 <br /> <br />Application Accepted By <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By <br /> <br />Soil Boring Ir,pcgction By <br />COMMENTS (7:r.; <br />oil Sampling/Characterization <br />Contact Name or Phone Number