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• APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BON 318,446 N.SAN JOAQUIN IT,STOCKTON,CA 86201381 <br /> (2091488 3420 <br /> NON-REFUNDABLE PERMIT"PIPES f YEAR FROM DATE ISSUED <br /> Ibeplow 1.TF4ReE19I <br /> MRICATCN M HOW W WAE TO THE SAN JOAWM COVNFV FOP A IEEMR TO CONRFM/CTM'ONR WIFNL THE NOM[RRCERNE0.TM!M ATNIN 1!MADE IN MAIN-t NCFW SAN <br /> JOAOIIM MAINTY OEVMOPNWRAT TRISMAJ ERR-1116.3.A/ND THE STANDARDS OF SAN MAdM COIIMYYPWLTH fro <br /> IRACE9,dNNMENFAL HEALTH WHOON, <br /> JOS ACdE..AWS L�>/—106 -O`Y CTFY ,TWC M'AS PARCEL AFVVAFNS <br /> oNTNRe NASAL !]}-ITn mEm; rna,Sn:chi ADDRESS 1600 W. L1N3HD FEDxv we 835-3596 <br /> cowP oP liR W El-illimAOMFRR P n C�T-lryx S11Rin VicFTSI 7X%Y74 MEDRE I71771"T11-7Fi15 <br /> M CONFTUCIOR SAME. 1�94J/1 IICS WONES <br /> TYRE nweuMNn ❑NRVL E3 REELJDlAmlr wEu 10 MWDowxR NeFil�yyus E3 vTFWR <br /> ❑nmA&EATm ❑wFu rr9TlM REENS ❑CAM.IONECT... 0vAPo.ERFPADFIONwaz9 J <br /> E3N.r0RNN x^ DEN,I TH.,AET_ET. Iwrwflrd ltvu o <br /> DHf OR RNM <br /> ❑OVFOFAERVICf N£Il ❑OEorNY&C.LL WFILI� ❑ 9dlSMMI I <br /> ❑ol.r.uerA+x: <br /> ffllr� O A <br /> ❑HDIIARR.LL p❑1O�EN SOTTOM 1 CU.OI WELL dCAVAICN 8.51 pA OF CON011CTOPCAA-IYNI O <br /> ❑PoME9ICRMVATE IO amm EAC1I/90I 'L TYRE OE CAMNOMIEIIN'2 40 TAX' ..,.F £ll CASINO 211 D <br /> ❑RI9ICMYHKVK ❑OMKH OFR110F OIIWl9EK TYIIITITTT Wf[IFlCATgN A <br /> ❑ ❑SYN. FASTWSORRY � p ± E <br /> 18 MOMONNO ORDVE ❑W <br /> LI W S <br /> Arnox.oErd 201 & 401 LoaRD wlart.wwrroYE MN'h3fiC Hnc a <br /> IIOFOSIO CONAFMCTIONNEwNO INISOO:MIC AMAW AM WTAW A.I. ✓ C.WE OTHER <br /> I I MED,CNRNY THAT I HAV!NSDMSS TNI.y ATMN SAID THAT THE VAIW W RE DONE M ACCORDANCE YARN RAN AAWM COUNTY OIEANANCd,STAT!LAWS.AND OVER AND <br /> �UNTON!OF ME AOUNFY <br /> F ARAON CW .HUM!OWNED O.WENREO AOENT'S SIGNATURE CEREHES THE PoMONMO:'I CEMFNV MAT MM TRERFO1MANCE OP THE MAR MR WHICH <br /> MAIOMT MIANE0.141AJ11bT EMM NMON9 BVSIER TO WOIIWAN'A COMFMAMN IAW.OF CA1➢OWSA.'CONTRALOP'S HEARD ON COMWCENO SMATURE CYSTITIS <br /> THE TO ICASHEY AT Ely RNOM1/JL!OF THE MEN FO.NNKN THIS RNM IRIMVf0.19M4L EMMOY RR,SOMR WBIECT TO WORpLY'A {D19AlOM UWt OF <br /> C4Ar1f0IOW�/I. Mn�OLAISS,N9lPo TO7 IlWITH-Mlt.OOMRlTE MAVTO AT LONERS/JRA MO C®. <br /> �,tl.(,L/ 'l//L,OIf.aYlillnA <br /> FIOT nASI RYIN ie 20 <br /> I.NANNIES MSRRTRO.REAM."ANKS SAEST TOO.ANDSOURN .D.TTHESEV. A. RAHEAT OF SEAVAE..d OOTIAH. MORIPoPoBEO <br /> !.WFIK WTHE ROFBIEY.DDW pMlOFOHS AMIIM AMOIMTIONE dP.IMONOFMLVME .. 9YREM3. <br /> S.dlIEN9OMSS OVFLDER AIO EeEEE H O'All d1OMO AND MOTIONED 9.LOCATOR Of WR19 WTIHM P e PROPS TY.MUNCPFD Pm R. <br /> (IWICMEER.NttUOEIO COVp®MAI NCNM PATN)9.MVEWAYR.M9 WN1[9. ON THE NCNflTT Ofl MJOIMNO PROPERTY. <br /> SFE rLLYonj M4P <br /> r <br /> \1 OBMTMd1 UE!ONLY <br /> Dwl Try�Sm Rr 0.,. T1mpRr.pslbn er DSS. <br /> D.Dwn N... . M w. <br /> C.I.Fw: <br /> ACCOIMFINO ONLY: AOI FACA <br /> IS CODES IR IKO NAOIMI ABMRO) CNMASFAAH REASIVEO RY DAF! FOMT/ADN'1EE FARNEST NLM9M I..A <br /> 350 8 q'lql ID121 b <br />