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' 09/07/01 12 32 FA7I 1904 <br /> 1- I- I --Lrz <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JCAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 334 E Weber Third P100r, Staokton, CA., 9+2-02 <br /> (209) 468-3449 <br /> -�"p�1�s1'1zrEt f v ttiCir TF r^ IN �.E pFR��rrsxpI '1`Y1-;�[2 FROM Z' �5 7 <br /> y nage a a^..ce^c ^Com'.^ti�-a 7::r',u tC.:�gSt.,[�'endlar�st3'I[hs 4^crk Ces�9aa r � - <br /> r� noun v Sava o r'a- ��`+G{: .a`or rs mxde r cards^ce nat-S <br /> D t TI a k-hao-r S 'a ?arta tI-e Srwr_a,_':or='rr ,nar.I,r C`r�n"J pcl1.rjr-61e131th S <br /> L Luc-;mon G <br /> ss�ree� rz C. _ ~xl�t ati - �5 as as a.sem s <br /> � __ r �C � •a _ <br /> rt { Y ` G8 G1FERTY % Aatros <br /> -anac'o Pncme <br /> r ILQ 3 <br /> -_es. <br /> ^{ <br /> C , [ + +vrr � .LVLy`�7�:�LLSP 177`�I O <br /> 4[-ant 3u'a cr raC�'r r.. "rte.:`* ,.1'"` , -i, I•�'I""I^� 5rfr moi-' <br /> f� �e. r•c.^ ass J +--� r <br /> __a rssooa x � CIr I�' ��-" <br /> h�" RFn►�N41=o <br /> CH <br /> [t OVEN-tCaSPE = <br /> - - - ❑PRESSU;ZZ GRL'LT <br /> '•1EN-�S <br /> ..�rl��L �S'/�5 4Lt TDv '"Y=G C�Ng�� Tf OIC 5P1rlyCi7G[CA71cMS 1 /� <br /> 11 TQ'�'1ilV lJ'!'�^..�lvJ1 Ss� j ✓ti v� �U�=•—Ji C: t�V./ 1.IL L—Ptl VA SIN S S^ YE <br /> C-('s `� -� - _ ^,K 4EbS SCSL ' S t4C n+SLL C ITC 7 A Z�1 <br /> ' --PE CF C;4 1 3 a S'EE_ �YC ❑G�En <br /> UR L i'L0 P�TLRY `r C)F Sc�L (v <br /> Jy � -.. �=� GRA+.,- _2 r- <br /> I nF�c P F.13' -� ` " � - C ! �^. r v.a�R� QTaC.�.c <br /> Fcl:vG ^4rJ _�"- CJw -epi [`v0 (iw107£ !1'}<4}CI[sRrJti1 FFc'c=-l" !.l I�E�Tri t5 30 ' <br /> ?r'ti C 21-X t � <br /> , Cl S G"�r1 <br /> ('F �.Y� r-s.�cec 6rasc-a Ncrs) <br /> tfEv;s _ <br /> NOTE. QFrSjTE SORINGS REQUIRE ACCESS GR ENCROACHMENT PERMITS <br /> repy certify the'3 have pruvareu th S adl]1)cation and +hat the Work will be done it accorciance wrth San Joaqu r <br /> 'Ity Ord[namc-US, State Laws, arc Re-gWatiens of;hoe Sart jVaquIn Cauftt� <br /> ' CALL THE UNIT P.1 )'vb�LCTCR�4B WORKING HRS IN ADVANCE FOR ALL REQUIRED 1NSIDECT{ON$ <br /> C.s `14 1ti.1•.r �� -^-�1--^�...., itlC:..an:anv ,� `P i ''-' r V � � iF -vL<' <br /> ITE MAP IN UNIT N FILE ADDRESS [WORK PLAN DATED <br /> /' D WTU! IN2Oy — <br /> IV <br /> rit?ReSo�SY ' ' <br /> mf— ren 'rtiLBGucn E:, Date <br /> v*s cotvcrrlaHs / <br /> CIINr,N.GCFSL`r i .%[Qp ! Il <br /> 1 >✓ �- I I <br /> 4C&3 I FEE Jlapu ,MOUNT ITEM 0 C?,r-0K; R5c:p Bgr4l DATE. PmRN1rr,3EF vm-6 REQVESf P I INVQ[GE <br /> 5�pi �4 u61 i T W 9 I , <br /> -:7 Lt-re- cf AL*f,o� z cn a *rik per-n t Encrcnch�ner- doc__-_ <br /> 1 <br />