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CONTRACTOR L..: SUBCONTRACTOR/CONSULTANT BILLING PARTY: ... OWNER <br />Water System Nerve Contact Name or Phone Number <br />INTENDED USE , Domestic/Private 72. Inigation/Agricultural Industrial Water Quality Monitoring L] Soil Sampling/Characterization <br />J. Public Water System <br />If different from Owner <br />CA74 '27 / EHD 43-06 6M/2019 WELL /PUMP PERMIT <br />DOMESTIC WELL SAMPLING: General Minerat/Coliform Bacteria (4391)=1 Dibromochloropropane (4392) c Arsenic (4393) <br />TYPE OF WORK f.] New Well r. Replacement Well 0 Well Alteration/Modification II Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal <br />)ANew Puma _ Pump Replacement n Pump Repair <br />Geotechnical <br />ii Cross-Connection Repair <br />Raise Well Casing <br />e of borings #0! borings <br />Area <br />"1 <br />Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />ft Constructed Well Depth <br />IAN t? 202 <br />TY <br />SAN JCACIU NTA <br />COU <br />ENV1RONME <br />HEAL11-1 DEPW <br />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 />NIT7CE FCF: 7 7"..7.ASE <br />TITLE a Djoifel IA e DATE --22 7752) <br />)\‘‘. pc- <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By VI' 6.1\0,11,0 (944,' <br />Soil Boring Inspectipn By <br />COMMENTS . N ofFoo.5773r...) <br />DEPARTMENT USE ONLY <br /> Date 1/2 <br />Date <br />SIGNED <br />PAYMENT <br />RECEIVED <br />47 V-ti"1 12-• <br />1-\41) <br />t1,,t <br />‘'7 <br />••••••••.. <br />Date <br />Date <br />-4 <br />PE <br />Codes <br />SC <br />info <br />Received <br />By <br />Check#1 <br />, Cash <br />Amount <br />Remitted Date „ <br />Permit/ <br />Service Request # Invoice # Well ID# <br />Vbq , 4 /4-01 11 26 /)-( tA100t11(1315' t12.2 2.71, <br />,.... I . 11 <br />CONTRACTOR ADDRESS P -0 - Box 64 cirysTATElzipLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />PHONE <br />CITY/STATE/LP <br />LICENSE k 0-57 C-61 ii D-09 j Other NUMBER 377923 EXPIRATION DATE 7/31/21