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l <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 389,44E N.SAN JOABUIN ST., STOCKTON,CA 98201388 <br /> 3 fv 120914683420 <br /> d- ABLE PERMIT EXPIRES 1 YEAR FROM DATF ISSUED <br /> XNN IFb iF TryhWbl <br /> MPVCATON W MRF OY NROE TO ntt MN J0110NN CDVrT'IDR/.VERME TO CDN6rWlC!MOpR IN9FALL TM NOW(OEfiCWRO.TW 9 AYFV RIEH N M•bE N COMNANCE.EM <br /> M.MCOUNry FMEAT TMIL 01MDEO10,1115.6.0 TNF SERSONERM6 OF EAR�QQ A�Q��Z��Lp12AN F TM SERY 'E SHRMSHORT.`.I`ORSINI <br /> Rx,RMIFEFTR RWF j�O 7-Ica��� -1 a �CIGNC 11G •CITY rr/�N�VaIl!��Y'Tn.YENS� FAICFL 61IE/AFNI_S�G <br /> _ OWMfI•.NAME�. EC. ✓ .,FFE�xM$se�hl <r. ` AOOPEb�^iyY[l/ L131en41/ 2d F«wcF2Lo7�170fp <br /> COHIMCEOn��G l I P Y A\ R I I�I M L. AOORE66 'J�. YYA V y� ♦e-2%'I SJ�xF.�161 e777ry <br /> WE COMMCEOP ADORESE NCI F1pNEF <br /> ryIE MYh31MIMF: <br /> )K.. ❑RFMCEMFM WEEL ❑MOMITOWNO WELL0 ❑OTHER <br /> ❑WFRSE'.. ❑WEIE SYarEM RVAw ❑ RONE.. FERMR ❑ SAwR pO1MCT1*..F J <br /> P9.Mwv[3RMxr r 3 OEEMFOMP6ET4Wi. FWIWATEA IEVEL /JOY O <br /> m OFwMR ❑Dvroo-sDRMCE WWL ClDEnWWMcu Wf,F ❑ EORAOWNo A <br /> ❑xcrRUcrloN: <br /> E TYRE DFw coxa <br /> ❑WDUSTRISE ❑OFE..OTTOM DM.DFwaL ucxvxnox x'�T____ __ EFA OF coxovcronuE D o <br /> �OOMe6TICRREVATE 'XOREEv FAC. '�Y =0,F MINomFFFwYc�l'. ."EIESSLE W. IT EL) <br /> ❑FDELIc.Nwwclru ❑daYAH OETTMOFOrovr 6EA1 E .,ET10N R <br /> ❑UWOATIOW1c ❑OTNER EMIR REAL INRu1EO SY EMIRESENDN"E E O <br /> ❑...N. ` DIMUTEEUFUENYO:dy. ❑XF coxcRETE FEOErturvORxLFR-jlI, R Ow s � <br /> •MIO S.OVIN !Y'�l IFJ `' IDIXMO CNFEFER xo.,iE NF S <br /> FROMI®COIYl11VCTMIIYLW WMO METHOD: IMID 0.T T.__ O,__AIR AOTARY SINNER CRAI OTNEP_ <br /> I ORENY CERTIFY THAT I MAYA PREPARED THIS ARI SHE THAT TMM W SSM SF DONE IN NCCOMWCf MAT"EM JOA N COUNTY ORDIMM,CEB.STATE"'HAS <br /> M AHD IS MO'�r <br /> PFOVIAlN1H6 OF TSRRJOAWCOUNTY.UNTY.NOME ONW <br /> MER OR LICENSED ACFNSSESSAMSECERTIFIES THE FOLVAN6:'ICEETN THAT IN MR <br /> E WORFAHCE OF THE NOM[IOR . jY- <br /> ISFERNIT ISMIEO.I MIALL MOT EMNAY FEN60NC SHIECf TO NOSINESSE COMEENMTIN 4W6 OF CANWMIIA.'COMMLTOWS NWNO OR 611EMNIMCTNO NONANR[CHOSER /O <br /> THE MO WINt: 'I COROY THAT SH THE FFFENO NCF OF THE WONT FOO WHICH THIS FEAMrt WIAI I ANSI.EMROY MRSONS S116JECT TO WORMM'I WMMEATWR IAWB OF <br /> CAt1FOPNI,AO'TIQ IIIPLpAIRpW�T y4E DtMWIM ADVANCE PoIF ALL RLOWRIWFST LMFItOLEI.COMSIFTEOMWIHO AT IOWERpEA fAO OFO �C <br /> IMT r M.N Id..,O SIH E„I. �u <br /> XPE660f STREEr6011 PJADSNE/.IIESTTOORS=.I.THE W10 TFNfY. t.IOCAl10N OF MOUSE SEWAGE d6POSIL INHTFN OR WO106EO <br /> VNM Of ME IMOWATY,OMNO OIMEN 610NS.WO XORTN RN IOx. EVMMON OF FAVAOE...SISTFM6. <br /> T. OMENOCNFO OVTIINEs ANO 1➢CAT..OF ALL FSWTINO ANO FW IOYO S. LO.OF WALLS NTTNW MW VS OF OHE NUMOPEO FEI FT <br /> 6T RUCNNE6.IMLUOMO COVETVO I SUCH AS FATOF.D AVG.ALIO WAIK6. ON THE MONSAIY OR ADJOINING RWWRTY. e/ <br /> b <br /> Y <br /> W � M 2U <br /> M 0 � <br /> m V <br /> 3 t <br /> PAYMENT <br /> RECFIvi rt <br /> JUL 2 7 1995 h <br /> sAN Jc <br /> LIC HEALTH SERVICES <br /> ENVI"""ENTiL YEALTy DIWgCN <br /> OFAMIMEMTWFOM�� / r <br /> _ A.Mm .AFI.._. �' Re-�s-vv--s�IS�Y �.r�➢ °'Ia '1/ZR/4 S Ar.. 2 I .�jj f <br /> O I Uen Br' boanbn Ry (/��A On. 9 /�4 <br /> ILC.I..ONLY: NOF FACE SFT <br /> FEFINOIF IIIEGNEST <br /> XWAf11 nV01tf <br /> DIe 38.R L!IY 1 -7/a7*' (o l <br /> w o �a <br /> 0 <br />