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09/07/01 12 32 FAX Q u.i <br /> F1_j F i IIIti- - <br /> F i�TI I FL.i II iF --GE0 <br /> WELL PERMIT APPLICATION FORM'! S1T�E <br /> SAIN JOAQU1h1 COUNTY PUBLIC HEALTH SERVICES <br /> MITrGATION <br /> �gpV4RGNPAENrAL HEALTH DIVISION (PHS-EVID UNIT IV <br /> 3G-; E Weller. Third Floor, Stockton, CA-, 95202 <br /> r - <br /> -_-( : -r- , '-�` ',209) 468-3443 <br /> r <br /> 40.4 H-rJI<4Q, DLL Pr-fl-ItArr EXPIp [ <br /> =t V` nvvb) �*2dg to'5w C��� " ��^ry = -=ter+ '+»FRn! I DAt% �SUEf] .. <br /> �C'13t 3 -' I^s f�r e C tiA �'a15 4 rri CCO C^��C ~s_S��==on mzat Cor-vJne^c9+m'--Sc- <br /> U--,I,. <br /> n�FcT,'Ow'-er � r <br /> ^r,&e3S— L. <br /> ` <br /> =uilart i rti Car, 3�J.1�.�L1�•,"`C!y►Ji rT.i�_ ��11"+#: �3s�CiZ� 1 L?tL. ��'+�QoTti.P �GL.� <br /> SEC`an <br /> tK - RrEl j1: <br /> SPEZ <br /> Dr -ELL v5- ^�i-• r --`-c CJti.rT.'2[,c7O.8E7ECI�.1,_T 0..� <br /> 4' -= - 41­ --m 'F.,i`.`5' 0 yEc �<,7C �L�C�rtirr <br /> S�Itia:E e_ <br /> R <br /> - iy'.tliz��n UGERS <br /> 5E acv <br /> -� :•,: "'Z� C Es {� an #h10-r� MAXIMUM PREF-J=AL:. DEPi'}i IS 30 <br /> '40 f Ot-r5f T E BORINGS "zEOUIRE ACCESS QFZ e=NCROr G':f4REMT PERMITS- <br /> oy certify tna.l have :;repa-ed ~IS a�ol.s:arion and .hat `he work will be done Ir accorcancr- wl:h San !osqu r <br /> in y:rd'•rartrz4z StatC LM.IVS arlc 'z"� eS and Regulators of the Sar Joaquin Coumy <br /> CALL THE :INr W IN5PEC rJF pie WO'?MING NR5 IN.4Dll,'NCEE FOR ALL Pi=QUIRED INSPECTIONS <br /> C;' ..l Y l 1 ` I f- J"`1 <br /> IN UNIT Iv FI� , ADDRESS ,VG�4 PLAN DATED <br /> cr Accaateti Sv Lses <br /> :-I rYS:aC3�n �3 <br /> ,QTS r CO►.Greto%iS Ide ob.&C_ <br /> 7"hG �41f r'' I <br /> ODES I FEE f,4FCldf U',i FTbtIT i�0 C.fc�t; ct^ i) ti DAT f PERfm-(SERVICE REQUEST•: xvp CF <br /> '� i 2 oil m&00Z. Z I <br /> �7 r� 1t1G "! _ rCt2 _ =7_z--¢- [ 7/!7/__ <br /> r-J, <br /> • <br /> i <br /> 1 <br />