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Plot Plan: <br />SITE ADDRESS: Brovelli Woods Lane, Acampo, CA PERMIT #: <br />A SE MA ATT CHE <br />PRINT: David Jarosz DATE 06/16/2022 <br />Page 2 of 2 Well Pump Permit U11)043-06 0410712022 <br />SIGN: <br />LICENSED VVELCDRIIIIV" <br />SIGN: <br />PRINT: DATE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> , hereby authorize <br />Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf I understand this authorization is valid for ore year and <br />is limited to the work plan dated on the front page of this application. <br />i•