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ScAD OArnk\ux <br />twiefOo Ftti CITY/STATE/21P <br />U CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />Contact Name or Phone Number <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring "Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name <br />PAY <br />FtEC <br />ENT <br />WED <br />SEP 2 12021 <br />Ul SAN OAC N CC UNTY <br />EPARTNI EN- <br />ME N-AL ENVI RO <br />EALTH D <br /> <br />Application Accepted B Date <br /> <br />Grout Inspection By ate <br /> <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTSZ- into r1•15C 11.1 05. <br /> <br />Date Constructed Well Depth <br /> <br />-7-10 -3 0., OS/ -z-10 -32 <br />EHO 42-06 6/11/2019 WELL /PUMP PERMIT <br />WELL/PUMP PERMIT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) :SSMICICIV 3.LIS I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MI <br />SIGNED <br />48 HZ ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE 3 kW- ,,rivylk..it,v DATE Ck 11 ID <br />teb 9 Area Employee ID# <br />El SPECIAL Well Permit <br />0 WAIVER Received <br />F -51€ <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />Cash <br />Amount <br />Remitted <br />Permit/ Invoice # Well ID# <br />I/372. /SO <br />"............ <br />S211767 9/ Z. `112:92-1 <br />Service Request <br /> # WOOth <br />ll <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />Cot borings 0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 91Geotechnical <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />O New Pumo n Pumo Reolacement n Pumo Reoair fl Raisf. Well Casino <br />DEPARTMENT US Of6LY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www slam/ ora/phri EXPIRES 1 YFAR FROM 11/1TF Issiirt <br />21ool wor-14n Ellio 12-d ci ram Lo 4 <br />PHONE J2.04) 4W1-11(O <br />CONTRACTOR ADDRESS "20 bt afic 4- C(- CITY/STATE/ZIP Galt ) C A 1 R5G 3Z- <br />SUBCONTRACTOR/CONSULTANT kiL)CtlICICQ .... 1441.11 44.- IFIEOSOUCt4e3 PHONE ( CI I (1) S1 2 1934 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1'1556 IYIAI-4 ilri a I $11 1.KA • crryisTATE/zip W 4264 '&4k1-• i CA 9S6q I <br />LICENSE 1C-57 0 NUMBER 19.0909 EXPIRATION DATE 4 I (312.0Zz <br />JOB ADDRESS <br />CROSS STREET 4NeDritlict• (La APN );PRCEL SIZE IS rt• 1°LS217CEISE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR 4-t.0 TX11\iri <br />PHONE Om.) 120-0 <br />tumbinivn Tx C. 202So <br />S7 2.-1 <br />BILLING PARTY: <br />0 0-61 0 D-09 <br />0 OWNER <br />Other