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uo: ❑--P Wayre Woodward <br /> lllitil"11715) i�:51 LF��4' 33 1 -707-374-5577 <br /> FIFTH FLOOR 1 <br /> �. <br /> %woe PAGE 02 <br /> :>r <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MMGAtION <br /> Al ENVIRONMENTAL HEALTH DIVISION (PHS-EM) UNR� <br /> 304 E.Weber,Third.Floor,Sfotkton, CA,,95202 <br /> (299)4689 <br /> 0IOH•RE &mPAgg Pg nmrr EXMEs 4 VRA �aaM DATE issues <br /> Wpm is hereby made to San Jooquin County fort permit 1a wnabud sm0oa Ia3t20 the! k1W cribed. This app4cal;er,'s msda io n—onmsm Wich San <br /> torsgvin co�aily Ge�tt4DM41ATstie,Chaple►9.1 t15.3 and the ft,m:k rRa o1 San Joaquh ckm"y ruble Rooth Servs,snwrmnmenloi Namut om!56. <br /> NELLLooa Da JV- W£>f Z-"e- Cromstmet &4_e'A1v_r C41 $"/'i�+f YFAI 73p Assessors <br /> ParCt:idr <br /> PROMtira ,.r r��trrr��tcr-� aeat�ss�°�f3a 3:2fF city oG � ,95�t ar>�rt� ��S7°? <br /> 'O �4 --?,3f IQ►o i✓ist�� gs��� �+��do f 3 <br /> C-STCan�acb+�i.��'o�L,�i'•)•�{1tr.11.�. /+ddrpe,,L �Y P <br /> corlwlhntf6ebt3orRrat+vr��� �N ! �3+-• A4dreec�Il�l�b I eJrA�E��C�1tyR 1,�v�i+�-uc T o/phoner B G-31�D <br /> CIS com kolfti.X Y .TOwnsnip Rn npe Seedon <br /> mac, es¢� 75uv-'P 4-v.- <br /> To <br /> TTO Lor PtRFO Etx <br /> FW WELL I SORM(CM,GE0PWAE.mYDROPUNCH,l MU-AUGER.OTHER? I1 s225rRLjCT10N IGseose type babes} <br /> U S01L 20 GIF 9 t]Vl:R•BoRe <br /> Pkessum 0")T <br /> 4xmr: Grout speelrieatiena• <br /> c OMMEUTs: r <br /> TwE OF WELL r3iM"A r"TYLE COm3i UcT*94.§P5qtFNn0XS�L 4/ <br /> MOKiTCR1N G LOW STM OLL 09 SORt:tiOL6�m JL nmr.CAW463S 11 YEs KNO WELL CPMMG OW,;r�L <br /> (I2MACTION pAFRNAMNERfoRtVSN GAS7HGTHfCIGVESSSG{�- TYPEOFGAStNG nS?£EL C O�iMLR', <br /> Q VAF+dR O MUD RDTARY or"of cR0ur SEAL,, c2 n l TFJOA16 TYPE TO RE USED: Nuts 1t9 ti HOSE <br /> 9♦JR SPARGE IS PUSH PONT GRauT S@d,vumrs=o: t(yes <br /> -FALL <br /> , j1.. NO�PA M MES DET30 <br /> (I=D NG 8H^P4I)At1GER GRWTSFE0FICATEONS � 6 LLHI <br /> Sr , 501.y-,0 7RAFC 80X or a STOVE PPE <br /> APPItOX GORING DEPT" <br /> CqN LCTUR CA51N3 t►f(OPOGM? i jr ym lbt aped6osdnrtehesex <br /> NOTE: Ol FSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PI.RMTri. <br /> CALL THE uHrr N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR A1^s,REQUIRED INSPECTIONS. <br /> 1 hereby oarVy that I ha,44 prepared this applicstlorr and"the work W111 be d"o in accordance with San Joaquin <br /> County Ordinances.Rult:s and R$gulatiors.and all applicable California State Law . <br /> � d _ Trt►NC�tpamy j r 6s,}7�!! JlDC9�?✓ v N� c Cr c <br /> psitrt N8rtt9 e.O�G�NG - I AJC10D W f!' 0 i Z ! d 3 <br /> pEp MENT USE ONLY <br /> SR'P mAP m UNIT IV FILE,ADDRESS: 3 a o2 t I <br /> woRK PLAN DATEDAppmm : <br /> oossa rsau 2 �»�. 0.3 ArOa 1 <br /> Grove t rrepeedOn_pted e7 6r ` Dere rol Impewen By <br /> Oesauckr+troneda+6y Oats <br /> COMMENTS7GONMONS: <br /> ACCOUNrm&&Y: AIO9 <br /> .. <br /> pE coDES Fie"m A=uNT EmffT90 CH t RECD MATE PL�RMlT/t3tiPt SRJiC(1 1' <br /> C-57, WC_,_, WAIVER C-57 Lctter of Authorization to-Sign permit_Enr:racK11Tn lrr daC, 9/2 <br />