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f 05/17/2006 08:57 2094683433 EHD <br />WELL /QW PERitif f QLD <br />,R aOAt]UDt 000M EK <br />XEALTH Ul7AaiR�! f 304 E WEBER Ava 3 FL-STOCKWK CA 96'202 <br />YIROXHOFFAL <br />;41�L 204 453-7697 Fok iNgPECrwNs TXP[RFg 1 YEAR FRdDM <br />CrfvJZ[r� <br />AYN Ph L Se6 ��LutD USA APrsaC.aTw" # <br />/:�c PRONE '�� q .. <br />OTYMATMtr 4w --K 9[C— 9'9'q 'r t j <br />—1 PwDir$ A G> _- "1 <br />I C l� r17 <br />CMMFATEMP L J`�rrl �r4 C°1 7 io l ri j ' �_ 71 I j ��✓/ L b)", <br />lfwsr <br />)0 ADDRESS <br />Ross STRCET <br />Wr4M NAME <br />�C� <br />mm6RADDRIM <br />!())jTRAcjVR AB -dM <br />;ttDCOMRACTOP <br />�scoK,'RAci+DaARDs�SB �� <br />rl C-fi1 O D -N <br />PAGE 02 <br />ctmmAwmp <br />NommEA :3`z7 Y:xrtpA't>or+GATE <br />3EOGRAPRacAL r.nnu.cm....,�.. •••------- ❑ Waler Quality pdanitaAaB L.1 ZIM <br />tu�xKDUp UBEU$E I7 Damea{IC+Prirax ]fr3eyAgfieUltmai d 1ndpS�a1 <br />UPublic%V-taS see wnat a <br />trdtb�rtrom ata axm aax <br />13 New Wd1 D Roplomenwat wdl <br />17 Moaiw+,, Weu(s) # of veils <br />❑ Out-0f.Service Well <br />M Wdl or ODM <br />0 Soil 30m%i5J �� �N u Geouchnial <br />DCNt.OfServica Well Renewal O cs coaaccranm Repair <br />Egi D ❑ Pah Point hcr <br />0 Oa <br />Drm1.6 Mctb.d Q Mud Rowry D Air MWY O Avgcr Calve Tool in d7Mww <br />r,.Posaawon 1�, — <br />R �„� in diameLLT ❑Open 9altetn O Otove3 Pack/ Gant Size,^. <br />in di..w i Cooduetor Casing A" �--�� R <br />Cm3u4h�CasmS Cl Saeel 17 Plt+s& Q Stoinim Sted tJ Othts �� <br />Well rf l CadDv=ta — in Thieb esdCkugeASTMI Sem „ e.tr J 7 �l valu <br />$ WW Geaxflt f� �+5 i F.10 gal water) D Sand Cuateat <br />Grout 6c■i Deed [3gp on File i] Space Sti>b.+i0ed <br />` p �cr t M% salsas) D 1Nm.tF+etura spat:9t solids _ % pdmne <br />n a..... A M Fk Fall D Other — Q Retardant 1 Aceektvw* (ansae? <br />ImhOed <br />6 Cetttraetar a <br />Widte R <br />Box 13 Sava <br />�— fl gub semble O TwWm ❑ tltoef •• �—WrM <br />1 HERESY CERTIFY TRAT I HAVE pRIPARED TMS APRLICA7[ON AND TILT THE WORK WILL INC TRAOrJU IN Y REQUIRED LICENSE <br />SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANA RULES AND REGULATIONS 1 ALSO AND <br />THAT <br />I Am MY REQUIRED LICENSE IS <br />CUMENT AND ACTIVE WITH T11£ CALIFO�RMA ()DN ACTORS 6TATE LICENSE BOARD AND TEiAT I AM IN COJtIPWANCE WITH ALL <br />WORKM comrE1V6471ON4AWS. n -- —.-%,smrncnPIN%4EC"TIONS _l % <br />S1*m <br />DEPARTMENT USE ONLY <br />Application ArGRA dBY ' Dons iJ <br />Cuaut Irmocti n BY Date <br />Pump lespendcn BY Date <br />CooWticted Wed Vgdh <br />COMMINTS <br />f1 /MAY 2 a 2006 <br />1-7 <br />Ara _ Emplov� ► L --`--:rte <br />d SPECIAL Well Pert <br />W AIV ER ReceiveII <br />PAYN4EN7 <br />RECEIVED <br />JUL - 6 Zoos <br />tN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />FALTH DEPARTMENT <br />