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WP OoWff WELL/PUMP PERMIT <br />SAat JCWMM COUNn ENVOONWWAL HEALTH D"AWWW 1868 EMIT HAZVLTX* AVS - SMCKTION CA SS Z* - t20% 4W3420 <br />NON-RuuNoAsu PE-qmT !CALL (20) 953-7697 FDA imspecTow <br />EXPMeS I YEAR FROM DATE ISSUED <br />ctyyfbp <br />. ........... .. PAW;*L SITE LAND UU APPL <br />0 <br />WfilEA NAME -ow <br />OWNfA ADWWSS <br />. .... .. Cn-YISTATM <br />P. <br />,c(mTwTAo"u <br />I ss effyist., z"'s %*J C -------- <br />iSuocowTAACTqn A ADORE" .. <br />_ <br />i '........ ...... <br />..------ - ----- . . . .. . ..... <br />....... <br />I L COW, 57 "1 D -W 09w ftJ0StA4kRKl11) E"MAUNDATE <br />Gfook~AL twomAAMN, CtxwdW*W X <br />Put w Wratw syswn <br />0 dA woo olom 0ayw. <br />- - - -------- -- -------- <br />�AqfW"W ft*nWtW , Wafw0ja6,tyMwftwiiV Soo SwooroVwtv <br />I miw V'A&M f . ...... .. . .. - - — - - --" -,-- i- <br />IffIqLAM Now Iffog Reptumoom woo WrA Aftwatim)AodGabon otw <br />Gootedu*W 4 C4 towv. <br />W-01-s*ro" WAR 04A'lcX-S*fv" we# Aw"m PAPAW <br />pillimameth,od turd wry Au Rotary , Auger c4ift,rca PL%h PorAl <br />1 Prtxp6"S Woll Depth . . . ..... it EuavAbW .... . . ....... . ws cf*nelat open 8040M , trawl Padvroavm s4z# w...__._ . .._ in dwoaw <br />COTXWOW CaSkV In diameter I CauliXtor CaSiN Dopth ........ . .... . . <br />Wali Cssft DwY*tor io ThiCknoss(CAlUosiASIM Sd*d St#m P"k stakoess stool <br />Or"S"i Dopth---il NaM Con*m t94 lb bag,'S- 10 VW www) sww s&O nW7 VA wautf <br />awftme SOW <br />lGtotft Piacanuml M*thod Pumped Freo Fail oftf Amolorato(imM) . ............. <br />13 <br />I HEREBY "fff*V THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDM4" *T8 $AN <br />J0AOV* COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATION& I ALSO CEATWY THa MY REQUIRE0,LICENSE ts <br />CURRENT AND ACTIVE VHTHI tMf CALWOPMA CONTAACTOAS STATE LWANSE SOAfW AND THAT I AM IN COMPLIANT WITH ALL <br />I <br />DEPARTMENT USE ONLY <br />Gf" m6po~ sy Date <br />Date i2 <br />P-1. lnspocmor <br />Sol aw*41 �— Doe . ....... . ..... ... ... <br />Ave <br />SPECIAL. W" ftt" <br />WANVA Rocot"d <br />00"trut"d wou Depth,-",tt <br />. . <br />C*d"?Rats vertl <br />. . ...... <br />Roftk*d <br />Dow <br />ulvoito w*fi 0# <br />.................... <br />----- ----- <br />