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Address L4 ]%,A' Qj'\J,r i <br /> 1 a <br /> ♦`�a.I S�(r� 1����� <br /> Site ID# <br /> Permit# L <br /> DtRS COMPENSATION CERTIFICATE <br /> ey agree to comply with all laws and regulations of the County of Sonoma and State of California pertaining to water well construction 1 will <br /> e ne (707) 525-6565 24 hours in advance to notify the Environmental Health Specialist when Completing or destroying a well 1 will furnish the <br /> e r of Health Services and the owner a legible copy of the State Water Well Driller's Report within 15 days in order to obtain final approval on this <br /> JA11 I acknowledge that the application will become a permit only after site approval anti payment of fee I understand that this permit is not <br /> rable and expires one year from date of issuance <br /> currently effective certificate of Workers Compensation Insurance coverage is on file with this office,made out in the name of the Sonoma <br /> jOunty Department of Health Services <br /> Date }" ` <br /> n1re of Well Driller—no proxies <br /> F <br /> trance Carrier v' r/l,/f G=�{ff-� <br /> Expiration pate <br /> ell wells/borings are installed,submit a Letter of Completion' to complete permit process <br /> icate on attached plot plan the exact location of well(s)with respect to the following items property lines, water bodies or water courses drainage <br /> tel roads, existing wells sewer main and laterals and private sewage disposal systems or other sources of contamination or pollution INCLUDE - <br /> IE IONS The validity of this permit depends upon the accuracy of the information provided by the applicant <br /> d f permit <br /> F <br /> I <br /> K I <br /> f <br /> S <br /> a11E USE ONLY-ENVIRONMENTAL HEALTH DIVISION •• ' <br /> it proved by <br /> Y Date <br /> I <br /> tr proved by Observed [ ]Yes [ ] No Well# <br /> Date <br /> orl well form doc (Revised 07/01) Copies White File Yellow—Driller Pink—Cnnsu}tant Gnld—Owner/Resp Party <br />