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cHSCHKL �- 1N1rHUt k31411/20/2000 16:48 191638` 'L <br /> ORIGINkL <br /> • ,w WELL PERMIT APPLICATION FORM SITE <br /> tr MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I, mT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> / ah, do <br /> 3E. Weber,Third Floor, Stockton, CA, 95202 <br /> 04 <br /> (209) 088-34Ar7 Te <br /> Onu_ee UrnA •PERMIT e1IPIRLt.1 nM FROM DATL IpD� <br /> A If honer nmde D lion JeeReM c'.ov+N M•Perndlle d>iatr�d euLa FULY*w wor%desoiDe0. Trb appala/aT N code Yr aoleper,aa Met Dan <br /> I®quY1 Cyunty D"%WpTw,1 TEM,ChapW. 8-1110A OW 1Rl�e!!Smr4W%of San Jt)OW"Carry PL"c"Ath SWAM,&*w-owm hosr+D Assam <br /> weuLeuSon `!lob CAm6ei0.�t , aYael tS cly�_pp��33� <br /> PROPeRn wmer J Imo" 33 ./M 7uNe ca„_Lf-lT7gJe�cI,P�m�'i'�`h3c3�?Plgwt '`2 b�Z—/(o?J <br /> Cm cano-.cm.l A�r'A�Y. M�//Iiir�X����dd.ar '� �i'nt(' t�!� ab ol�llr LaIl.LAyI�Q q>h r <br /> Ccawbnl i soo Cwf,somU=T l-f,TC P. �ee,ee. I � � /. 42�-3��0 <br /> Me C0vWisILC% Y .Tom-W_ Range Sedco <br /> PERFORMED; <br /> ri WELL/50RIN0(CFT,OEOPROeE.HTOROPUNCH.HAKO-O 1IG16L OTHIEW) 0 DESTRUGTKM(dnoee W"b"W) <br /> p sdl "1a O 0 ZweGRE <br /> -e m m <br /> —�----" p RauQE IlRovr <br /> COMMENTS: <br /> DTL91FYQII tlOTP 1PT�DM MO WELL GA91N60YLZ <br /> �(IUYOWTORINO .. -,Xi7LOW STEM DML OF RORIHDLa MULTIPLE CAS►aOST D YES. 10 <br /> pEXTRACnON 0AI14-KAMOVDWYEN CASINGTHGOa'.W TYKDFCASINQ DSTEEL *,- DOTFot�. _ <br /> p VAPOR 0 MID ROTARY CATH or GROUT SLAL Z _TREME TYPE TO as UNR D AVOaFO 0 HOe¢ <br /> p AI,RSPAROE DPJBH PONT GROUT SEAL PUMPM: DYea *a IN OTE: MAX MUM FRM-FALL DEPTH 19301 <br /> 0 SOL 8ORING a Kk%0AUDFR OROUTSMCIFIGT10Ne: T®TAPFF7C a= W OfTUVM PIPs <br /> p OTHER. n OTHHR APP110JL bom"a CEPTM �� <br /> CONDUCTOR CA6NG PROPOSED? NU (M Yaa.ILA apedSballom WI <br /> -Care!(Ta: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 44 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby Yvrmy t t 1 A pmplmd tbla applitaftn and that the wvr$iwill be Cone In accordance with Oen Joaquin <br /> County Ordl n ■, ea and Reyulatlona,and all app0aybls CaIlWrnia StaN Laws. �rC n-1 <br /> TIO.Icn W, � 5 l9 r S'Ca Sf f/r <br /> Mn[Name G tYl GY r-j- Deaa <br /> pt=�nRTMENT USE LY <br /> SRE MAP IN UNR N FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> _ Dale k"uW1/ <br /> "P?kaben Ao uftd Flnp Inaprd<ui By <br /> w <br /> 3routk+Pc11�U aY Deb---- <br /> JsabvNo+In dim D DIa <br /> :ONRENTB/CONDTTFDNa' �C t�� <br /> ACC01 Kma OFILY: ADP <br /> O gYDUNT REMITTED CHECK* VWC'D VY CATE IiRYR/aaRNCl RaouaaTe aivOCa <br /> PE CODea FEE WF <br /> 2zu DD <br /> C-57_ WC_WAIVEF_-_ <br /> C-57 Letter of Authorization to sign Wmit_Encroachment dor`. 9/27!00 <br />