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ppYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECOp9E® <br /> ENVIRONMENTAL HEALTH DIVISION �r,�p I�a413 9Qg7 <br /> P.O. BOX 366. 304 EAST WEBER AVENUE STOCKTON.CA 94R W,QwiI 'e;'I2N1 ES <br /> C209j4sun PUBLIC HEALTH ".� <br /> IIOR•REftlmeLE tomff ENVIRONMENTA:HUS-' 'Di �d!SION <br /> APNCATION re{fEf@ BY MAGE TO THE 8A/1 JDAOUDI COUNTY FOR A PERMIT 70 CON9116KT ANDg11 N6TALL THE WON(OEBCNB®,THIS AER1GAnON 16 MADE PI COMRIANCE WrtN BMI - <br /> JOAOUN COUNTY DEVELOPMENT TRLE,CHAPM 8-1116.3 ANO T!E RANDMOS OF SAN JOAOUN COUNTY P'UUSUC,HMTH BMV 6,HIVIRONN*NTAL HEAETN OMIgN. <br /> Jos ADDREB6AIRAPN. 15'600 alar(u h R o ct d CRY L- 1 In,pY o� PARCFI 6(g,APN. <br /> oWNEm ~: pla�HAOOJ Mtj Em43Z, AOOR[et P'0- BOA `157 , NUI IASd NI A PIANEf <br /> ooN1AADTN Myavlc. d (,,.o Foly)rom M,I7ZlI ,TAC.ADORE6 1(903 1.f HIVCLJ Ln,LLL:B4M)-;Z PHONE, 5'6'0 6 j <br /> 6UB CONTMCTOR {=Nyi V'oprd�d c ADwEa 3315 Mary I,ot11q, flnabJl t"icB 64017 nwTe r�i4-446'S1i 1 <br /> TTPEoPwamwr ❑ xew wEu ❑ HEPIACEBENT WLLL ❑ MGNNipNA wEi1• ❑ DTNNIt <br /> ❑ NRALLATAN ❑waE.BYcrEA RfPA1R ❑CR08GW WiECfwoum ❑vAP011 vaRAc oN waL• J <br /> 13 13 R�pW N.P. DEPTH PVNP KT_". FUST WATER LEVEL O <br /> (TYPE OF PULb) <br /> ❑ OUT-0FCFAVIC[WVE11 Q fIFONNYSGAI NCLLB SD0.SORRA B <br /> ❑OE6TAUCTAN: <br /> INTENDED IIAF TYPE OF WQL I� A <br /> ❑NOA.TRIAL 13 OPEN BOTTOM OA.OF WELL MCAVATON DM.OF CONDUCTOR GIBING — D ' <br /> f ❑ oOME6TIGFNVATE ❑NUVK PALNMRE TYPE OF CABINNSTEERVC� DIA.OF WELL CAWNG D <br /> ` ❑KWX AWWJPAL ❑N[vEl DEPTH OF GRoIrr SEAL T- D 6EC61C►TIOH pp - R <br /> l [3 ROOGATANfAUS ❑oT OROtR Rx N6TA11ID R onoLrt[RAJND HAMe i 0f�'ION Cutty �' E <br /> Ip,6NormowNo r ORow SEAL FGMPED: ❑v.. CIS. CONCRFTEPEDWA BYDRUEC❑Y.. 04& s <br /> 1 APFROx.NBTM I S LOOtMO CNE.TTBt Box1STOV[ <br /> 1 1RGPOBED CON[TIEIOTONAN6WNO M D: NIA ROTARY AIR ROTARY AUCEA CABIN OTNEHd;rfGl PUSPt <br /> 1 NEVFDY CPO"THAT I"YE PREPARED THNI A CATAN AND THAT THE WON(WILL BE DONE N ACNOANCE METH SAN JOAOUN COUNTY ONxHANCE6,STATE NWB,AND RULE[ANO <br /> FEOULATANS OF THE BAN JOAOUW COUNTY. MOME OM R OR UCENM MNENPB INONATURE CERTSES THE FOU.OVANO:'1 CENiF1'THAT N THE FE FOIWANCE OF TM V00AK MR MMICFN <br /> TT R W t66UED.I WMI NOT E.IPLAY PER6ONB NNJER TO W WMAN'i COMF6MATION UWS OF CA11F01BYA.' CONTMCTORE IMNO OR BUBmNTAACTAiO WGNATVIE CER10TE6 <br /> TWFOLLOWING:FOLLOWING: '1 CERTMY THAT N THE PERFOAYANCF OF TME WOK FOA VASICH TUB PENRi M IBKIEU,I BNALL[MCO PTTSON6 NQ A T TO WOR9AAN'B OOMF@IMTON UWB DF <br /> CMRONAA/' THE AMXANT MI1)6T CIW.IJN MOW N ADVANCE FM ALL fROUNFD U61'[C110IM AT PPBI.Yi.T]. COMRTEi[pMWINO AT LONA AREA FroVIDEp. <br /> 6*n x XmB -- A tl(�`ti�/I.�y1� TN. 5emfoo 5T'aff 67 o1BR151 <br /> P10T IT/IN ID•.N a B..I.1[d. �b <br /> .. f. TYJA[S OF sT1ET:rs OA roAOB NEMER TO on BOUMORA THE PADFFRh', a. UOCATPON OF HOUSE eE`v O®'OBAL 6YBIEM 011 PROPOND <br /> t. OUTLINE Of THE PNOF'ERTY,NYNO ONMEHBAN6 ANO NCRTH OGFLDOK ExPANSxN OR SEWAGE pIBPDeAL 6YSTBB6. <br /> ]. DR UCTUR ED O{RUIFS AINO LGCAiION OF ALL AS PA1B AND PROP AYB. i. LOCATION PROPERTY <br /> O omlof RANUB OF ONE MWIDRfD NF1Y R. <br /> 6TRUCiIIRFS.RtCUW10 COVERED AREAE BVCN At PATgt ONVEMIAYS AND WNKO. ON THE PIgPEiIY 011 ADJORMA FTgP9{PT. <br /> ........ ..c .... .v <br /> MAP Oil BACK <br /> iOFPARNMBNT U[ONLY <br /> APWMNbn A.P.s1N <br /> by, <br /> i .y <br /> i. (YaA Ir.pmUPn BT Ota Pump DPPt6.N1 BT D.n <br /> I D_vwmn A.P..Us•6Y DNF ' <br /> 1111 C.mmPN.: .. <br /> ACCOUNTING ONLY: AxM FMB <br /> R CODb ivBA'_W0 AMOUNT BORT® CNBCNBICBW ffi y [Y pATE PEpOTNEryR[IKOVFYi MB.V81 61ypq[ <br /> O , t04 <br /> i w .. <br />