HomeMy WebLinkAboutWELL-2-11-15601.TIF y �'�o
�T d y �
� �ESIDL�'d77A.L vv�i.�. coNS�urnon x�coan
� 1Vor[!s Carc�[iaa Depar.�aent af Envaoamem and � laLara! R�cu.rr.,cs- Di. � of v►�ier (�aaifty
���.� 2 �9: g
WELL CONTRACTOR CERTIFICATION #
t.we..i.cortrw�ctcr�: f. aos�: Ty� C. ��►^�-- a�ount c � 0 2
���'- S Q? `t� � �. t�ua�rt zo�.s tc�stn;: +s �
weN Cori7� (Indiv�dw � Fswn � To �� F�n 7 �� lo '��
L- ._��_� ��t`� i'� � e' � 1 F�mr� To Fc�n Ta
W tName Fc�rs Ta Fran To
STft€ET �DDR�SS � �� O �h� ►1 C ' � fi. CdtSf � e � . II _ � Ue
" T �, '� � �rorr. Ta � � Ft� (o � N
5►. rrr,1 [s �.� �1 e �� 3 !
City or Towr► St�e � L� Ccde f Frcm To FL � I
70� ��{ g.3 9,��� f� T� �
�..
Hre3 oade- Pl�cne number
T. GE20l/T: O�th t,Aett�od
z wFU. ��: F� o Ta �`� �. N n�� } e Fav �t
5���.����, a— l f�� � 56Q r � �o � ---�---
STAT�VYS.LFERMCi'�{x�pF�e�. Fsan To F�
QWQ a O'FH@t P�MiT �(iE �fej 8. SCFtEEN: Oe�th Gi�n�r Si� Siz� (���ral
WEIL tf5� (Chedc �ie Bax?: R� W�er Su�ly EI F�n Ta Ft in. a�.
QA,�� 3-- � I�- �-� �� To � A,. �,.
F�mn To R iFte. in.
T!lb1E t:OlYIt�LE'fE'0 .J . Q 6 AM Ci � U
9. SA�'oRAYEL F�ACK:
�. YYEil. LO�A r , D�Att S§ze �
�'�� � 1 r,r C c�r� � b� � �fl �.
cmr: ��' � S G co�mr
F�oan Ta Ft
Frart To Ft
(� NarsrC tdcrosDer�. Carnr�wuTy. S�sFCn. C� l�b.. Pa�el. � CaceJ
TQFOGRAPHiC ! LAl�Q SETTItQG: g � D�� �
�SlaPe Ov�leY Q,� �R� 'L�� Fram To . Fa[m2�s� Qe�i�s�
fch�cic �te banl
May 6e in dc�vas,
�a�rr.fu� 3 � �..�.�� �` �ti'" 5�....4 _
to�o� '� $ �"�"
— — l�v°'t��' Z c '�
Laxitude/longilude so�arce: E�GPS C1Taga�hec TnaP �
f�rr of t� rrarst Le sf�n �► a tISuS tayo map �
attacited fa tfris fwm � r� crskig GpS)
A. W�1L O�R
o��s� Ba�� ��.L� z�.�
� ��ct�ss �1 �Cn'i Sp r n►ns � o!' �i � W�y'P Ze re i
�►'� t ( �S .�'O!� � �� 7� �
Gily ar Taim 5tate � Cflds �
i t
Area oode- PhrneB fnts��
� fl. �.4.ISF��:
s.;ov�DEr�i.s: 3�C�
j a TOTAL D�PT6�
b. QOES �L fftEPiACE E�iSTI¢v'^.� tN"c�.l.? YE8 �:SO p
C. WE�TEF� �.�L. S@�'JQ T � t CK} NB�Y CERT�Y T}b1T2lf.S MIE[l'd'JAS CpC3STRUC:Ep Zy p�D.3C�'CE WtiFi
�A �9� _. �- t5si e„CqL 2C. c'YELL COAf31RtiL`stCJ�f S 61Ta9FP.D3. AMD SHhT 4 CAQY C3f 7'{�
{use `+° �� T� C�azg) � eecaFro �as e� ro hoe mr�u. aar>�R.
d. T��aF���,�� � �.���- �— I(� f 1
°?ap of c�g Eemrst� 2�tor �+auu I�f sw�dec� enay r�e sC�n1AYU oF fzr sE� cacdTRACraR af.7E
a vmi�nce iT ce vufi� 45A PiCAC 2C .Ci 18,
a. Y6�Ld) (9g�enj: " '� �9�TP{L1Q O� Y�ST V � � � `�` � �
�� PFYt411YEp P4A.q�E � p�RS R9 CO{�BSTR'.9C i otdG TFi£ WfEl:�
l:..L�4�L_ _.3�i_�0�' a�__ vwf"_'__'_ _ ���s . w ..� .".. �� . .