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1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-;:420 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /># of wells 0 Monitoring Well(s) <br />y Out-Of-Service Well <br />IL New Pump - Pump Replacement <br />Airke <br />20/6 <br />YmE <br />tij 4 0 <br />EHD 43-06 <br />4/30/12 WELL /PUMP PERMIT <br />WELL/PUMP PERMIT <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS <br />JOB ADDRESS \ \ 1 )50 \i Q1 p; C. e TZ A <br />CROSS STREET 1;1i .1 L. y 1-• APN g-N - (AL)- 0 l <br />OWNER NAME IS(—; --il-cy 1:--- 101/ p LLL <br />OWNER ADDRESS % 41:1 Kj a‘Z \(\j Li y <br />CONTRACTOR C I ) rC-% 61,1 14 0(n4e -VP 10 I., , <br />CONTRACTOR ADDRESS trii ..31:' ''%r ; (1041,k7 Ni, ii PL tftz?_.5 <br />SUBCONTRACTOR <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />PARCEL SIZE <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />CITY/ZIPn 3--)& <br />1 LAND USE APPLICATION # <br />PHONE 51 - <br />1\ Cr-ty eit-1 <br />oNEc---u5 9k)-290e, <br />C P eit62 <br />TYPE OF WORK Ft New Well [ ' Replacement Well 0 Well Alteration/Modification ri Other <br /># of borings CI Soil Boring(s) <br />Li Out-Of-Service Well Renewal <br />0 Pump Repair <br /># of borings Li Geotechnical <br />Ll Cross-Connection Repair <br />rl Raise Well Casing <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />NTY O$DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />ACT E WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />PEN ATION LAWS. <br />R INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DATE 10 t- <br />/ <br />jAt1' t4(Jytv V/40 COU Aftv- , • <br />N <br />EN <br />A <br />' IV <br />,Frrm <br />Application Accepted 0-- -----11A.Mh. .. Jk.. <br />r PrITMENT USE <br />Date ( <br />ONLY <br />Area Employee ID# <br />Grout Inspection By Date E P CIAL Well Permit <br />Pump Inspection By Date E WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />lEly <br />Check#/ <br />Cash Remitted 1 r <br />Amount Date Permit/ <br />Service Request # Invoice # Well ID# <br />4)7b4 1162 dis2 1//‘,„____ $«1.0) 8 /1 0 /(0 LCK 075H 2 <br />4 /) <br />JOAQUIN CO <br />CURRENT A <br />WORKERS C <br />MI <br />SIGNED_ :SSTIGGV aLIS 64 <br />PHONE <br />M Z4 HOUW ADVANCE NOTICE REQUIRED F <br />TITLE