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MAY-16T2005(MON) 09: 32 -- -CGRS FRLIFOR NIA (FAX)91F 991 1177 P. 0021004 <br /> 11104I]IIVCOt1N7YENYrIIottMrvrru.H6ALiaDI rMn1tEVY 3D4MWrz3=Avd 9"trL-S:0CKmrjCAg=z-(109)469-420 <br /> DN-R 4AD[.>y P nrtrr . CALL U9)95-1-7697 FOR I Y194A nWM DA7'l MUE0 <br /> aAut>MCl crtrntr <br /> tapsnMET I t_ C o - AI'N --f a0 ;� P.0 Sfrt t"> r LttmvLI=ArFwwATiaNN <br /> VrOMN&,im o 0 0 o 94:�ar 4 <br /> vNa+twIIDnrrr 230 3 ,�� a ob G IVIG E �t.(Lr-LE- MTYl5TAT=n- L o-0 I l CA (?.T `rte <br /> ItrttteCCiR WA(-j-0 4_5,C r,rc[ PtttlNt 9J-G--3 1-3-l t s I— <br /> iWTAhCr=Avun= -a• B o Y, /t7 z �rrStarfcrzzr f l�- .d-cro - C'A gs64 i <br /> 5CENTRToa rnarur. 0) tr G1�l l o O <br /> 9.2, <br /> :>cmr. t l C-57 M C.al n 13-09 1v' luul►tll 1 lvu >axPivA.T1c0 Dari% 10132 to l� <br /> 0=AMncitt.NVQVj4A*nQXr taarriiad�s 1; Y T�ttashlp Ilnrt{Ca Sadioa <br /> 309EILK)FI; 0 Dom=dclPrivam CI IrduadaalAe-cultuta] Q Indudsiol Q Water Qualify Ntwlmrin11M 51311 5arnpliep/Cha uqn <br /> D <br /> ItrPve WhEa5yeturn <br /> nb t oem tywtmrt amo a or mt er <br /> gF,_Qpwaas; E3Now Wall O Rcppta==1 Wdll ❑Wd1 AlMrttlonfModiliaallan t�t7 cr r=:c �-A_ `^ /1. ..P � <br /> Q Knillart:tg Wall(iL-10 crwdlG 0 son Bating(s] florbor011Ut Q Qt:atsahnicol L¢ftlatlhax <br /> 0 culKir-serrim iwop 13 Ouo-W-Scivlcc Wall IItntwwlol 13 Ctv= aC=cc lan"Upnir <br /> t7 <br /> NcwPum O puny Rcyin=mmir M FuM2 H=p2ir <br /> ILL Cmt lyrn-r nit <br /> ]Ilog MaMod C1 IdudRatary C]A1rRn=y C)Aupr O Cable Too] OPuslt Point P7 Purr, jy A- <br /> TROAad W4 Depth-L' ^.rsualian to dlant= 130pu Iludom O G=wl ftrkl Owl Sae In cflamdrr w <br /> �C�tdadar Caring la diameter ! CanCuctar C�.tltlg 1]cplh R V)Welll.C=Iur, Dl twtcr ltt 'IhidTaecrlCnuf7dhl;rM tlt:llad b 5=1 C pbstia O 9ltrinloat 0tr a! O 131.hu <br /> Grout Seal Depth ,1t OIVmrCensne(9rlb9rSg/�/Dgaltc QswwCmmt mrkm�ly�sfvralar m <br /> ❑usmMbllc(U%solids) O Maauftt=,ar SPQ Ql.nalidl �5 r IQ"tt�r 0 5prtc nn Pi7r 17 Spera Suhmllt� <br /> n,e MUCCIrtant Matbad O Pumped U F=Foli O Otittr��„"�_ p Ralanlaot/Arzdll rales nlurl-� <br /> IA=lledIly OndUrr OFumpCanrractar Othcr ) <br /> 11CnnwIteP'ti1mml 111Mt tlP=V/ld%h ... n Lattpth _ ft7lriak In OQlrittylia:_L1BloMrC1ipr <br /> 9- 10Sub aniblt OTurbino OOtriar L{P Pu &CL BStats �YtttorLaw] h <br /> rP.Elnlf C;;KUFY T%AT I SAVIt PREPARED'I 5 APrLWATMN AND THAT-nW,WORK WILL BE DONE IN ACCOR4ANI=WrM SAN <br /> %Q11 COUN'CY ORt711+tANCZ STATE LAWS,AND kULES AM ARGULAT101us_ I ALSO CCRTtFY TR#kT rdY RZE7QUIMED LIC10181C I <br /> RRMTX A"AC ME WITH THi:t:-/lI.=RA►MA CONTAAcTamS STATzticENSE t10A3rw AND THAT I AM V C]pAtPt IANC1:WrM ALL <br /> IRKF2R5 COMetMxT11Dp LAYS. <br /> 1 mrfraunt zaHOUR ADVANCE NOTME REQM?ZM VORINMcrralNS c <br /> vanCly <br /> 4 <br /> i <br /> T <br /> ED <br /> 205 <br /> SA- <br /> DEPARTMENT <br /> - <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �'�-7 Area Employee ID# s <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 3. 3-TS3 Ll (o D W, tiu 1 0 S "L It,3 E: <br /> EHD 43-02.006 WELL PUMP PERMIT <br /> 1/27/2005 <br />