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15 01 2094683433 FIFTH FLOOR <br /> �fi FAX PAGE 03 <br /> _.... <br /> f WELL PERMIT APPLICATION FORM - <br /> '. SAN JOAQUIN COUNTY SITE <br /> ENVIR0NMMrAL HEALTH DEPARTMENT (END) NQhl <br /> 304 E. Weber, Third 1~1var, StvolF n, CA., 98202 VNrr1V <br /> 7Y1�(ITI�f <br /> (209)468-3"9 <br /> N014-REPilhF0A9Lrm A Ml's ffl 0 �—ft <br /> iftAPP tEo�ryi ei�s Y made tv 5an JoaQ�n Cocln V far s peemft la ccnslNcf andler irtcta 1w work des laad. Thm appOcalton is made to <br /> COIr+Pllarfte w i 58n <br /> It7mI '�eveo "F� Chelplar 9-��4�4,i�UrWdlthe Standards of Sari JOaq um C <br /> aunty EnvkanmeaW Health Oepaui"M <br /> PROPERTY �Q a ch.# aracs <br /> 067 fpr �`' <br /> G011mattlt, <br /> GJSCaordinatea;X Y ,Ter"hlp _ �9� SertFor� <br /> rr� !E� <br /> R $Qa'tllVG# (CF'T,G'EOPROSE.HYDROPUNCH,HM01 1G01,OTHER? Q pES�RUCTIOK (rasa typd 1�foM <br /> t2 OVER-BOM OIAM <br /> 1tJ91"tI�Y�H'�E O 9l71�Ctkyr`.IYI'f <br /> NG <br /> I=Xi'I3Ati77Wt1 LrAW STEM t)W 0P'SO�OL�-^�, �Q MU�LTIP�YLEpgCA8h33 �ML7l�VEL CA5NG OIA:[ i 'Rts4AH1�DR1N ASr71IVS .o <br /> ` <br /> OF CAS N(3: Q STEeL a OTHER-,— <br /> a vAJZDK U MUD ROTARY DEP7'M aF sROUr SSA TRE14llE Trpa TQ ea L 3WE it At7GFR9 ss <br /> 9PARQW OZONE Q PUSH POINT(*P or CPlr)t3ROLrr SEAT.FUMIIW,- es (}Na (NOW: MAXIMUM FRS-F/41.I.pgPi N IS SD') <br /> BORNd 11 AMC)AUGER GROUT SP.ECtFIC 'f10N$ <br /> cmi APPROX BOPMG oepTAI 7Ea TRAFFIC POx ST&ge PIPE <br /> CONDUCTOR CASING PROPOSED Bats kiamm mskaacron} <br /> KmwTsL 'p Av3 <br /> NOTe: OFFSrrr= E36RINGS REQUIRE ACOS AGREEMENT ENCRr HMENT PERMITS. <br /> 48WOR10NO HOURS N(ynC9 FWQUWAD FOR INSPECTIONS. <br /> I harp-by c"tY aMt 1 hey$prepared this 2PPHcaf Ori 8nd"UK the W*rk Will be done in a=0rdapm with San Joaquin <br /> C�DLMty OrdhWRcas,Rules and Regulat#ons-Arid ail APPRU413 v CRWOM 4a State Laws. <br /> ✓mesad �rr?•�- �7'�1��✓ � R <br /> hYltttl+Fd 7�1d/C.omparzy.� <br /> DEPARTMENTTUSE ONLY • <br /> WE MAP IN <br /> UN IV Ir1L ORESS:`���� CJO- "C 00 <br /> WORK PLAN DATED: <br /> A#pnt0GtoI I �' <br /> lnspechon By Data �r�tl lm;mcpon spy - <br /> oealrudlgn Iran� - <br /> coMears col�vmorrs Stop <br /> ACO=N17NG CNL•Y, 10.1Dlt FAt�I <br /> P$00009. P11M INPO AMOVNT I�STrED CHECK# V00c�BY DATE rte' PERMIT t S13i1�GE RECiUEST# 1>nIYCBCri: <br /> �- 8 Oho v sR# p <br /> �.•` We- -WAMR- C-57 Letter of Authorization to En <br /> permit craachMC" ar,_ , 91$0102 <br /> 4 i <br />