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19/81/2081 10:13 707374E <br /> 19/@1/2981 19:11 209- yd0AWA?D DRIL.LINr- ^.0 pp,� 82 <br /> 226 �6WSTO ATC <br /> 0 <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> n� <br /> N`JOAQUIN COUNTY PUECIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL.HEALTH brylgION (pHS.EHD) UNIT IV <br /> 304 E.Weber, Third Floor, lltockton+ CA., 95202 � <br /> . (z49)468.34i9 <br /> am <br /> � Z <br /> wec.4 <br /> W, t4 cmv s ���, <br /> . �' n.��'�-til,i�ad� t�ia. • �, � .. <br /> • '.c..'s�►Cantsa4r_S 1w�k.+d+d ��.�non�r �lidto 03'#3 <br /> ..C4Gv4 lWd 130 CoWmdpr An ASS%wka ,Ao&am u w.Wtj OaIH, _c+q► ua0 <br /> �t r,860PR a,HYOW NCC WAND-AUOR t,onUU" XbnTmucTm bw bwv . <br /> 0 �s a <br /> Q PRESK laR aRDUT <br /> Tg: �deu�t • <br /> Ii 11>nALLATlOI1E <br /> �* <br /> 2211IMtuCT10N aSMSATM <br /> p mom"M" p"mww swm oar aF em Mt1L,TIPLI CASINW Q res %ft wau CWNQ OW <br /> .11q,1crvamw p AIR KV*CR wvtirt Casa T p0*-%& �epF C NG: 119ML 0 PPC COMER;_. <br /> _d vAP�oR p MW WA" I*m OF oPtOUT r M TO as LIM: WA XIM p t�E <br /> ;0-A1R wAm p PU&POW WIMM SM PWK*. r*s No (NOTE: MAXIIYIUM PR1 9-FULL DEPTH '15 301 <br /> r9CRNM6 p tiANO AtigER C1rlp lr s clF�Car s: �w�`- 5104%- <br /> APPROX DORM Oil Y" S'4� 5 OOt7�D niAFMiC 80X or p BroVE ihpi <br /> CONE'fl.lCMR CMM PROPOaW?JM �(r YK*.Ret @P@dMW N tW,): <br /> NOTIL OFFSITIF BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> a"TIS UNfr IV M110aft di WO M13 HCWPW IM ADVAMCE FOR ALL IMUNKD INSPECT1CNs: <br /> .i >r ►that 1 haw prepared this appltptlan and that the work will be d4Ra in rlacardanv'r M11Itl{San Joaquin <br /> Cc4mrY Q"xnrnea, ulm%and Regulations,and*4 appIloeble California Stats Laws. <br /> f�!►i1 Nllnr ('b'a' H �`�0++ti Oaat ! at <br /> DIFARTMIM USE COW <br /> pm No IN MT IV 1°LLE,,ADORE St <br /> illlllllwl <br /> L DATO: <br /> AMMed asI //- Z <br /> 00hopt Iimewn ar we F. . l!wIlAan ft D�N� <br /> o�w <br /> ;obi s/0010/10 ae <br /> �. ;/i�`CGfl1MrNMG ONLY: AR7t <br /> "'00X01a . M114110 AMOUW Rl1A11'TED C1MIMK f awc aftbAll PO MAR'I sw x PEOU Sr a INVOICE <br /> • 5longL <br /> d. W -WATM C-57 Letter of Authorisation to sign permit-4 Encraachmant Joc g/Zr1t10 <br /> co�pss�a <br />