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03/10/20@- 13 47 2094583433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FO�M SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NIT IATION <br /> U <br /> ENVIRONMENTAL HEALTH bIVIS1ON (PHS- HD) UNIT 11 <br /> 304 E. Weber, Third Floor, Stockton, CA., Sr202 - <br /> (209) 469-3449 <br /> NON REFUNDABLE PERMIT, EXPRES 1 YEAg fRON DATE ISSUED <br /> ,wr_alon Is-frebp rri4a U Sae dcaq.li-County for a pemur o=G,?,.a andlar ln1 *,a4 Ste wo-fc�esulas� Es�putca len Is�.a�e rr�rAuancc vrth 52r <br /> '$vag,t^Cou-Ity Cevelcpr^enI W.%Chapi S-1116.3 orsd to Stantla-da O!San JOA,U1n Couniy FuDlIC HeaKn aMees Er IIIcr renuj,Peal:,D1Vsfor <br /> � T �;wSa� <br /> W3L_taeatTn2r77-Ao 11~IF <br /> _ r Cross SLoct TI.6tr��� CI`Y �� flarrxx <br /> PR0aZFT-C,-,,C,,4 IG"S _ atdless1L .,a, � clr��_zK���a1 �A 95�-9�5 <br /> C-47Canftvm*4ZymA=as ACcress tf�Dr �_Clry��rx�%ti L j ^onz u�,-87i� <br /> ev=61'antraubcvvaclvr rLdXpj 71M AddL-es Grr Les Pho�e�$S�rSi r_ <br /> GI9 Cos pnaces X Y Township _ IRanpa Gees^ <br /> Y40RK fQRE 111ER90R48C' <br /> 0 PlSel WELL fECF HS(CF- GEOaPOSE.HvCRC.PUWt+ FAN.'-AUGER OTHER') 1xCES"RUCT"Cti k:�ocse Pyxs_eigwl <br /> C SOIL AORGUG N <br /> c <br /> %'.vF%LL# VLlW k-.n�.w`7 <br /> 'CrIor GRML f dons E VA.. <br /> 0091 r.hJ7s u+ NAW Lf1 C�1" <br /> TYflE_ P'03 _L INSTALL4TIONTYoE S,_U'N$7PUCT7CNSPECIFICAnoms <br /> 11 r,C J,rC&.NG C-10' LCN STEM CIA OF BORE-IOLS ry�JLT.PLE G.$NrSO �S �N:+ WELL CnrNG Cl... <br /> U ex.,ACT,Ch C AIR HANIMEP-VR-IEN CASINO T FVCK%E5S hrE CF CA.i (I51 EE!_ Q=VC <br /> . n VAPOR L,VL.':)ROTARY CEP71-1 CF GPCJT SEA!,_rq-::UIE �ryE TC ai USED 3, r'E ks p SCs: <br /> 1]AIR SPAF+GP- II=1.15H P0414T GPOIJ7 SEAL PUVPc:; ❑Y05 II Nz INOTE M�XIMUM FRE=-FALL MOTH IS 30') <br /> Q SOIL 9G;;,NC 0-'Arles AUGER GROJ�SP5+CyFICATICN6 i <br /> p C itE-Zy 1 P!� A=PF{GX BU►IIVG O&r l riQ EO TEC TRAG-+C 3C< at 7`7`!y PIPE <br /> CONMUCMR CASING PROPCSED') r rye IIS spe-Icatms-1ce _ <br /> 'CCh4YE4TS <br /> NOTE. OFFSITE !BORINGS REQUIRE ACCESS OR ENCRO CHMEN T PERMITS. <br /> CALL THE UNT IV INSPECTOR 46%VORY IHG HOURS IN ADVANCE FOR AL REQUIRED INSPECTIONS <br /> I 1,er?by certify tl•at I have prepared this application and that the work will be done in 3C0brd2ngv w th San.Joaquin <br /> Ccuntyori inane !es and Regulations,and all applicable,Callfornra State Law <br /> sly-o:x —1 4 er".' CaT� <br /> DEPARTMENT USE ONLY ci <br /> SITE MAP IN UNcT I4'FILE,ADDFt:SS: <br /> WORK PLAN DATED. . <br /> A--pg=cr A":cpred 9� r� . -*-a Issued r � <br /> Cre.t Ins;"an Ey --ll Date rma InspeWaft 6v Cate <br /> OCSt�,cSon'reoeeexn <br /> ?y <br /> Data <br /> r,0MhjF-XT3 ICON DI IONS <br /> AG:G�„7,MNO014LY =4 <br /> MCC ES F2EINFO AMOUNTRENrrrEA CHECKV RECMBY DATE f PERrv4T18vmrIGEA$0'.esrti 1 14YQICm <br /> Am Z 17�-- Gb` Ak 9/o 4/ �DZ7 3 S 1 j <br /> C-57 WC -WAIVER C-57 Lester of Authorization to s,gn pe.-mIt_ E4craQc Meet doe_ 9f27Ml <br />