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_ r <br /> ^1�'1}J P:7...l�.Qf•' �iti'1� 3� <br /> WEELLWRMI T APPLICATION F miTS <br /> S I 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> A <br /> ENVIR: OMEN T AL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 ;—::. Weber, Th- 7ira' ;-Soot-, Stockton, CA., 952-02 � <br /> (239) 458-3449 <br /> PFIZM r?XP!P£S' YEAR=;ZOPA GATE fSSUED <br /> is h4umoy made:D Sar.:Cactjr;Caurm-icr a permit tG C--nstrUc:.andlor:rlsmll the we-m descnbeL'_ T?ti5 Z;;Pt:=t3or.d5-nzjz:.:COYG1i2�=e wT-5=-. <br /> 3_L[.-1 .CC:R_s izveicome^_'1;1�. viaG:ar S-.,,'S an--Ine stancar--s c'San., a4:1;'. u.^.^, -Enviim men•ai Heait;, Dle•i <br /> ��-j A ses.za:z <br /> ___Loot cn Criss a Cr., Z.=1sG�p <br /> .�ntactorcrks vli+��T?iW 1Z ° Ip / IVV <br /> Lc1rI h vII't� l vices, �s <br /> .rmultart 'Sub Caniractor c iT U— : oLM } + <br /> . 7V <br /> 3::==mates:X Y i ovmsh:� Rerge Se.on <br /> :);31c�C S! PFRFC ZJ'A=!): <br /> J«'rte•V'ti'? f3CnlVC f.^R r_^Op?nqc u�'C17^aUP;:' ir::v-:i'�E DTH«Z'. D«S'R <br /> l] s5 L BORING <br /> --noose c,ma <br /> :her: GR.^.:'T 5rE ::,TION <br /> ;t„1Ml_hrS; <br /> oc OF WELL INSTALLATION`„=r CONSTRUCTION SPEC1FiCQ71pT1S� x <br /> ^�'TORiJVG H^LL^V`, a vS �;;. �=ESR=^moi=�_,SSL_T: CfiSINGS" eS Q `JC W=- C STNC-DW �yof <br /> C"F+rFC fL`FJ [ AIR HA,'.!Sri=Z it1Et --ASING ^!CKNESS "'Y?=O C.ASCNC: tj S i E�_ Q F"./C �_ <br /> F Z,R '" ' PO T AR`r --E?Tr'0=CROU7 S=A.L i^n. L ~:�. (�nI:GcRS $'ri^.: <br /> 3 'Ry ?i1SH r Ctr1J" GROU- 5=A. P'J1:a3 es Q N� (NOTE: MAXIMU%1 FR-==--FA-, '- D-PPTH 1S 30') <br /> :lfL SORI'lar Ct i-ANIr AUGS; G=(cu-s=-CJFi:F iOL /VE4 T -- <br /> i U SOJ-7C..;mAF.:C 3YX or 13 STOV= <br /> CCNU 1:TC,R;ASi vG�?OpCVE�"�13O(if YES,lis;specificaUcns here): <br /> NOTE: ©F:SITE SCRINC-S REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> ereby certify that I have prepared this application and that the work will be done in accordance with Sar Jaarsuir. <br /> runty Lrdinancas, StateLaws, and Ruies and Regulations of the San Joaquin County. <br /> x .ALL ZH UNr 1V 4SPECTCR 48 WORKINC- HR5 INI ACVAN"- `OP, ALL f-EOUIRED INSPECTIONS <br /> c x TitfAfCam�anyhIr 1 n I 5 <br /> Name Oa•e <br /> 317E MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> .IE,4on Accepted 5y ` Date issued <br /> 0!:tspection 6y_ t �., - ^Dat: 7 1 Oda, =inaf lrszectfon By date <br /> �:'iCn insmacton By iOate <br /> MVENTS:CONRfTIONS: <br /> COUNTING ONLY: AID# <br /> E COCES m INFO f AMOUNT REMITTED CHECK# � RECD BY ? DATE PERK UT/SERVICE REQUEST W j INVOICE <br /> si t I I • 0 c' IF S• ,�r' r IJSR# z <br /> F7„,_,_ WC/WAI'VFR C-17 Letter of Authorizaticn to sign permit Encroachment do--_ 7/I7/00 <br />