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MAY-16-2005(MON) 09: 33 CGR`- �RLIFORNIR (FRX)9t-s 991 1177 P. 003/004 <br /> WELL r PUMP PERWr <br /> LNJUAtlLWCotM *EIMMl3tttVaR'-rALHrLA TrrbktaWMS1t MdEWM=AY=3-EL-SM=0NCk 457.A'I-(3U3)46B.34n <br /> O3Y REF[lA,TtQELE3'>rRhi[T CALL 09 953-7697 MR NwalON'S =FUMS I YEAR F=M DA3T,=U&0 <br /> ' N <br /> ,u tsunas X00 alb LAra� CT• crrvrzrp S otlLrn.t Z z.. n <br /> C, - C 7 77 } <br /> tyytl=AAMICA-MOn�I <br /> • Nnts+c ���A2�t- L C N N A�A A �+;G E Plrnat92o_4_ <br /> xrr�a AISD E1T� 3 S S O a A <br /> 3 R ' - PNOt96 �'•9Sl-116o <br /> g�Kl3IACTD 4 ' <br /> PSiCtlt <br /> IICJOIVTSiAGTtItt Rtp,7, CrtWSTATVZIP <br /> calm= OC,Sl 13 C-61 ting ;A01h� ' u� S�iPAILtT7tJIQD�xe Q <br /> :oassartuGs.I>tttaltvtantIIs= Cavr ;cats 7: Y 7osra�ttlp Ranru 5cdiaa <br /> ItFr, ❑b=C tICTrfV= M TrriCadanlArrlcurwral ID G+durtrizl O wnrta Quality Mtmilaing II SoILSatrplm JCf. rrizallan <br /> O Pttblie WamrSyyzz:t;M <br /> IfdfBtynnr�wnpwr,ct s.=Mr4s1mbrpw n <br /> 'tti0r=M+rsM 014m-wcn MPxpla=mentWdt 0wcnAI=dan/Mo&15=dan Omcr — G <br /> 1:3mmin=inl:Wcn;,* oofurdis :2 Sollinrinzo) ❑t=tsknical oalbur+tt>m <br /> Q❑uD.Or-sm-,oe wcu Q Cuo-Qf-Gerufca Wen Iknewal Q Cr-?,CwM=%I0n ncpalr <br /> D cwTurnti ❑pu lace. ❑P r <br /> IM09Mcmad b Mud Rntary ❑AIrRatly II Aver II M13ig'ran] ❑Tush Pain[ #thcr <br /> mpoaed VYaR tL.Pffi it Eiraratien fa dlM=1rr II OM Ebtlnm ❑Gr-vel Pads I Cuavel Scx�^In dl_,.fm J <br /> ©C=ductor CU1nz_.__ _- la dlnmat;x I Cwdu=r C�"1ng Depth R <br /> will Cuslap Dim== Trt ;hldcmnJanul AUR Schad ❑steel Q Plxtir_ Cl St hd=tat--rd ❑other <br /> GrouC6oal Depth R ON=Clmr,etttlltl1atoJ-5-/tl2a winterj 0-q dC=Cmt srrckmlr/7Bsl�+�ua <br /> 13 Rrnttmitc I XV.m113) II M= S;=y.9alidL _q Tlmcc C35p=s an Felt d 9pccA Suktniticsi <br /> -MPb rm—tMMbd OPuuwd oltmFall 13CIth= []Rrtardaatld.*-tcralUr rrtvnc) <br /> dSo_ L_ IrLnz led By 0 t?rillcr MPump caamzirr Qllttr <br /> R Canrntn Pcdrst�l IIimm.icoCl�+Idtlz ft fcThlrsc la ❑Qtr ila�t II HLarc P"i r (l�1 <br /> ±iR ❑5u M=t1h ❑TUtbim M04= t3P Pump9 fl Gtandlv� 1Satr Ct trot Tt <br /> MIUMY CRRTI>Y THAT I HAVE PREPARED THIS AMLCATMN AND T'SILY'771E WORK WILL BE )ONE EN ACCOMDA1tiCE WITS SAN <br /> AQFIIN COUMV d=rNA;YCZ&61ATE LAWS, AND A111"S AND IXGOL0.bDN& I ALSO(:I=I1IFY TfrAT MIC nQi3inz.D LICS.Ns6 IS <br /> KRE7C AND ACT1W Wtnc Tur,CALwu MA cONTRA,=R5 STAT$t,TCCNSE-DOAAD AND 7nAT I AM IN clamrLmNcr WM(ALL <br /> )1=95 CQIt V=gSA.TMZFN LAWS- . <br /> Iv��Irnl.�.i��anvaa�rcE>va�gic��quu�D rolr.�rsl�c�vr►is ,� <br /> 1 IVEN <br /> F LE D <br /> 11 TT_ <br /> 1I , <br /> 2005 <br /> AJAUtEIASTM <br /> )ART <br /> 71 <br /> A DEPARTMENT pUSE ONLY <br /> Application Accepted By // Date p -/ 7SGS Arca Employee ID# <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 ReceivedCheck#/ ,. Amount Date Permit/Codes Info B ash Remitted Service Request# Invoice# Well ID# <br /> EHD 43-02-006 <br /> 1/27/2005 <br /> WELL PUMP PERMIT <br />