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4PN U00 -44-U4/ PARCEL SIZE _U,/_ / LANO USE APPLICATION # <br />PHONE 209-662-3843 <br />CITY/STATE/ZIP <br />PHONE 209-466-9625 <br />CITY/STATE2IP Stockton/95203 <br />PHONE <br />CITY/STATE/ZIP <br />ether NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br />:ONTRACTOR LI SUBCONTRACTORICONSULTANT <br />Iliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />ricultural - Industrial 71 Water Quality Monitoring F Soil Sampling/Characterization <br />Wa[er S f -tern Name. Contad Name or Phone Number <br />ell Well Alteration/Modification Other <br />yells -Soil 8oring(s) 4 of borings n Geotechnical tt of bon,ngs <br />Out -Of -Service Well Renevral - Cross -Connection Repair <br />tent U Pump Repair _ Raise Well Casino <br />Auger U Cable Tool _ Push Point _ Other <br />Dn in diameter I I Open Bottom t l Gravel Pack. -Gravel Size in diameter <br />imeter I Conductor Casing Depth ft <br />e!ASTM Sched I I Steel Plastic Ci Stainless Steel h <br />:ement (941b ba9/510 gal wafer) _ Sand Cement mrx gal water <br />_ Other U Retardant i Accelerator (name) ___ <br />Contractor Other <br />Width It Length It Thick in - Christy Box n Stove Pipe <br />HP 1 Pump Set 120 it Standing Water Level 96 R <br />HIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76,97 <br />TITLE CEO DATE 6/9/2021 <br />ENVIRONMENTAL HEA! TH <br />PERMIT/SERVICES <br />