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~b3 d65 .559 P,~J1iL"~.= <br />cws.s~ NOT]CE OF lNTE~IT TO CONSTRUCT <br />otl~ot Please cy?e Or print Legibly to b <br />t < : ,N <br />.:;-';, ; <br />- •' I I;- <br />r L, •_ _- ' <br />-- J <br />Wz!I Owner.; ~~°van'ie //yy~,T,__.__,~~_ <br />Landcwner's .Van-e (,L:. ~ V <br />Mailing Address: (AuthauzEd Individuallar Duller) <br />~~ ' <br />Contact _Il~wi^w._~.ee..t C~,nF ~zwypn~o/lrw>ta/~e.dna.z~if <br />Company Cll. f`£ ~~ ~ ~I~na LOed~gNV <br />AtldreSS ~ Cloj( ~~n( Q / <br />Ciry. State. Zip VtL~01rt 4a SO$(vO <br />Phone 7~9~Cr,bYY-tfp~s Fax NO. 7'19 ,~.~'_.. <br />Dauer L;c. No. (ir applicable) 71'fC_ ~c ~~N~~ ~Qil~a~ a K'11r <br />29 <br />TOwnsnip TS ~ Range ~a H~ ~~` =~r <br />Cocnty ~e frcr <br />Subdivsion rU~p <br />Lo[ Atll~ . Slk ~1~ . Flg~~__ <br />Hale{s) to he Ccnscucted: Number _1_ <br />Esumaced Cepcn:~FC. AGwPzr <br />°zupasa Or :Nengonnq Role(s) <br />G'stua,a( We~e,r Wlow~~annc~_ <br />Apprdximace Oate Of COnsttuctwnJ~ +~ ~ R 5~6~ <br />ACKNOWLEDGEuiENT FROM STArc ENGINEER'S OFFICE <br />FOp 0«iCE US"c ONIV /1j/~ <br />Q~~&~ Qr -J <br />Ai1H- pacceSSEO 3v ___YYYY <br />olv. `U `,ire I?- s,4, _ Mo _ ~aTe ack.voe`J!s~cz~ 3- 23 - o y <br />GaOU~IC c! es <br />USGS Mae m <br />CONDITIONS OF MONITORINC'i `r-'OLEACKNOWLEDGELv)ENT <br />A COPY OF TH£ WRlTT.,N NOTICE OR AC%NOWLEDGEmtF `rL SN~~!L'3>=~.4VAILABLE AT THE ORlLS.1NG SITE. <br />Notice was prov~oed ;o cbe Sate EngineN ac leas: 3 days poor ;o cdnsc-.c: en of mon~[enne b ccsarvanen hc~e{s). <br />Conswrion of 'se nae(s) muse oa Ct)rnpie;zd w,tnir, 50 Gays Of ;ne va:.=.ncuce was Slven :o ;-e Statr :-Ga~°°r. <br />asanq and/cr pumping sndil opt oXCEEC a LO[al df ?OG hduN un1255 cnOr wnCLEn a0pmval is Ob[ained .`rcm he $[atE Engineer_ <br />Watw diverteC during ces::ng snstt Hoc ce used for beneficial purposes. The owner o/ cue Hole{s) is respansiye !or obCatning petrn~c(s) <br />and complying wizn au nile5 and regwauons perta;nirg [o me disenarge dr 9Wds produced dur.ng ;astmg. <br />.411 work must comply with the Water WElI Construction RWes. 2 CCR a02-2. Minimum cdnscucnon standards musz oe met or <br />a variartca dbcained. <br />Weu COnS,ruaion and Test Reports (GWS-31) mus: he suomitted to cTS office by me licensee conzrseor or auu,ar;zed Ind;vidual <br />within o0 days of cue <omple:ion of the work. <br />Unless a well permit is ootai0ed. [he Hole{s) mus be plugged and waled witnin due {l) year ater cdnstnxticn. Art Adandonmenc <br />Report (form Gw5-g) musz oa wbmit;ed w;cnin o0 oat's df plugging 3 sealing. <br />The owner of cre Hole(s) snowd maintain records of water quality testing and suecrnc this eats m ;ne S[ate Engineer upon reGues <br />The monitoring ode nymber, owner's structure name. and ndla owner's name ar+d address must ae prw~ded on au well permit <br />aopliwUOn(sl, weu comrucden and abandonment repots. <br />.~ .monitoring note cannot be convened cd a droeuction water weu, except rot ourpose5 of remediadon {recdvwy) or as a permanent <br />cewatenng system. If consvuc:ed in accordance witn the water WHl Canstfvcdon RWes ana doliciES of ;ne State =ngineer. <br />7}e5 ACXNOWLcDGF~NENT Of NOTICE GOES NOT INOICA TE TNAT WELL PERMYf(S) CAN BE .1PPROVE!]. <br />NQLE(~t ~ , R?`C6JU~D <br />U ~,~,} (NAR 2 3 200? <br />WRIER nE50URLE5 <br />....~ i~i-.' _,~ 7~ ST47p ENGINEEa <br />~p 1J •~„ ~-~~ - COtO. <br />l.L~ = V C"fD~ MrMre< A LccatEdr.:•~_/, ~lE %. Section <br />ACL.tittdnaL GdrMiUOns <br />