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n M WELL/PUMP PERMIT <br /> SANJDEQOIN COIINIYENv1aONMENTALHFALTt DerARTMENT ]III EWEBG AYE 3m FL-STOCKTONCA95t83-D69)4dBJdSO <br /> .NON-REFUNDABLE PERMIT CALL(202L953-7697 FOR INSPECTIONS EXPIRES 1 YEAR PRgM DATb lssueD <br /> g$IX� 5 f�w I. g • l �' <br /> JawDDaLa gTvrzlP 1/AL{.! <br /> Caoss BTRiEr rbi&- W - APN L(J`I 170-02 l <br /> �Y �/PA�R/C�[L gIZSC�i� IL1.1T� <br /> OWNSA NAME - PNONC Ill!—'S H.-F6(J AGI <br /> OWNRRARDRESS 5u41d. <br /> CrtY/STATE2IP---- �CA LICi�S' �4 — <br /> coxrwcroR jj,e� �tt r �}� rucinE 121D4-23NI^—o5/g <br /> CONIMCTOR AOORLSS LS8 T J.. CRY/STA'RRJP 6:6LUOKI CYC- e1SZO6 <br /> SOBMNTRALTOR 50f L�YM plumne <br /> __2Q4- vtiS-RAIZ <br /> SOeeoNraACTOR ADOREa 'L b5 LyI.�S...A Yi-'J( crev/sTATV/i�rP 4pl'ILi- _�Ll C1/S"jJa; <br /> LAccemE C-57 CICfiI Cl D.09 DDater NIMe![R jp E%ngATtoN DATE y 3D/p (p� <br /> GWOR ICALINFORMAT1ON: coeNhlRtn % 3 <br /> Y Tewnehip_ RARE, SeeUm <br /> INIENDm USE ODomatiaPrivMe D lydprioVASrieultuml L71ndt""El OWMa QuAliry Monitoring O Sml Sampling/ChAraaaiatim <br /> D Pubm Waters <br /> ucimmu mem t� <br /> TSTEOFWOaK DNew Well O RePpcement Well :D Well AlleratioNModlfxalim 13 Test Hoe OOther <br /> m <br /> ❑MonimrinL Wal(4) .m.f-m Cl Soil Bo644) mmbv°rmnep ❑Geotshnial °O°'hQ°r6who <br /> Well Dsuuelicn m(}II Yl p�� OOmOr-Sm1eR We11 OOm-0f-Service WtllRrnewLl <br /> New PO D leammt O PUMP R O Crm4Cmnection R r <br /> WELLCONSrRO IM <br /> Drilling MabW OMnd Rmq DAir Ropry DAupr OCnbb Tool OPum Point Cl Other <br /> PropMd Well Depth A Euendon Indiemaer E3 Open Boomer, OGmvel peck/GmYel Sitt_In d6melM <br /> OCondMlm Cain6 indiemaer / C..ckwu Cldng DcFb R . <br /> Well CMIn6 Dtamaa_In ThieimedOeogr/ASTM Sehed O S wI Cl Phmle D sw.l ta Steel Cl Other <br /> Gmut Aal Depth.ft O Nae Cement(W M dog/5-/Op/vnj OSend Coma[ nr,Fmtr/7pl wapr <br /> O1lenw-IMO 'AWIMs) O M-01-3--Seen%WIWI % NEW OSpenm File ❑S <br /> Croat Pl..I MMhod O pumped O Frte RII O qAM Pea �� <br /> D RepNem/Aceekntm(oamc) <br /> PEDESTAL Imtalled By ODrlllar OpumDCoehacuM DOlher <br /> O 6xrae Fedrwl Dlmeedov: Wldm R Length B Thick in OChrpry Bea OSmve <br /> Fwwr OSubmerdblc 0Trbine DOdpr Hp_ Pump Sa—_A Standing WaMLevel q <br /> WELL DE4TRUCDON D'(pm BDnom Cl Gnvd OUDeeMd f �• <br /> Dgha <br /> Well Diamaa Z In Tops Depth 1_R Depth m Wetu�$_q O Geing[o he PeAmetMl rmm <br /> 6eegng MAlar41 Nat Canal(ph lb bug/J-/Oyal wrrrJ aswCemeat_rmdmtr/7pIwMM G.BMOMdp Peliem <br /> O Bentoniw GOIA Bolide) OMenuhaurM Spm Sd eW(dName OSpm ao File OSpas Submiped <br /> Placement Method 0Y..Ped O Free Feil D Other <br /> OCooyepwithMahmom Rbclmpvft 0 Complete to Riming S.M..Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 51AN <br /> MAQUIN 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> IWIMJU�M 24 HOUR ADVANCE NOTICER`E1QU�lI/RED FORINSPECTIONS <br /> � �-y <br /> K1`f DATE ;.1Z/`l3 <br /> r <br /> \ \ <br /> / <br /> A L4oD'gyRdB <br /> p r ata A. <br /> 6-1' ®Z A <br /> -O ] 1 L E,nPloynnlw 1456 <br /> _Drout h spwm By <br /> Nf ._ap _ Q- SPECIAL Well Permit__ <br /> Po� pttasy Dep 0WAIVERReceived__ . <br /> Oah <br /> COMMENTS_pvmTial By Ceutrvcpd Well Depth It <br /> PE SC Amount / RMehM PerMO <br /> Coda Into RemittM B Dap Servhx eeaM Iuvahe6 Well IDA313 � 0034035 <br /> EHD47-0I-0d6 <br /> 5//2002 MASTER WATER WELL PERMIT <br />