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C�yy3, 0 i `�° WELLJPUMP PERMIT <br /> SAN.JOAQUIN COUNT 6VIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOGKTON CA 95205-ROM(AT ISSUED <br /> NON-REFUNDABLE PERMIT WWW.S OV.Of lehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> n �i215 m <br /> JOB ADDRESS W iM W • � CITY/LP 5D <br /> M <br /> CROSS STREET % �vM� C R��4 APN PARCEL SIZE LAND USE APPLICATION# D <br /> �_s H <br /> 1 �. F.esi "0 W\ q{a� PHONE l/�!'�� 1 1-9051N <br /> OWNER NAME T <br /> OWNER ADDRESS V W'C VIA, CITY/STATE/LP �J�A. U <br /> II�Qi{ <br /> CONTRACTOR l\� wok a ��j�->t�—� 5\.)o PHONE <br /> ,y``%A)-I4A-1%� <br /> CONTRACTOR ADDRESS L�3� - CrTYISTATE/LP�_ . <br /> J <br /> SUBCONTRACTORICONSULTANT N I� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIT/ISTATE/LP <br /> LICENSE xC-57 )(C-61 I D-09 I I Other NUMBER EXPIRATION DATE ZZ Rt <br /> BILLING PARTY: I OWNER I CONTRACTOR I SUBCONTRACTOR/CONSULTANT \J�� <br /> DOMESTIC WELL SAMPLING:I i General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)i i Arsenic(4393) <br /> INTENDED USE omeslic/Privale I Irrigation/Agricultural 11 Industrial r1 Water Quality Monitoring r I Soil Sampling/Characterization <br /> Public PubWater System <br /> If licent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1.. New Well -1 Replacement Well 11 Well Alteration/Modification Other p or borings <br /> 1 Monitoring Well(s) #of wells a Soil Boring(S) u of borings I Geotechnical <br /> Out-Of-Service Well n Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> New Pump yNpumpReplacement <br />