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APPIICATIOR 00R PERMITy <br /> SAN JOAOUIN COUNTY PUBLIC 'HEALTH SER,..jS <br /> . ENYIRORMENTAL REALTR,DIYISION ' x <br /> ' <br /> 304 EAST wEm AVENGER STOCKT K CAfi <br /> (20% 4OU4202 roi Floor" <br /> „� M <br /> - NDN•REfU1IDARLE PEAMR [r <br /> 1 <br /> A9lICATIDN N IIEPE BY MAX:TO THE SAN JMMNN L9{INiY FOLIA FE111Ar TO CONSfRIRT ANIDOR SlNrNl 711E WONC OESCIBSED.'THR APPLICATION/6 MAGE M COMPUNICE L11TTN BAN <br /> AODM COMITY oevEIoPMBrr YTnZ CNAPM�RI .1L111/5..3 AND THE CrAMOA/MyO OFF SAW JOmmN C011m PUBLIC"ATN MMCEB.HWIIIDNMBMAL HmTTNAOMADN. yy1/� <br /> AODIOHBIOR APIM�1t� 11 k 1Q)Jy1.�/Ho rnmo La FL C.,yT�J-jC_1./�11y5�)n�ic� 'IMCaS� �^ (hrrvn+ <br /> 57 NAME_�U�1�� 1 I _ - ADMI�B11•- l��o .�✓ con o <br /> (coMvllnl�//STC' A!,w_ >�1 C3 I n h T nC ADMeBB (OPIn � f� 5r Dr 7 <br /> w'' N�'Fciloo-5 30b <br /> eoxrRAeroRo. r. AVMREa/ a 0 707 , 374-26 <br /> oP O WW WELL ❑ IOPLACEMU vent ❑ MoNnoIENO WEii• ❑ oTHMI - <br /> I] M4rmLATON ❑ waL SVSTESP REPMR ❑ C s&COW=T SAM ❑ VAPOR SXrRACIIM WELL I <br /> O NPI,,❑RMF* N.►. - OEPTN PUENSET Fr. FIRST WATER IEVQ ` O <br /> 1rvPG OF PLILEPI ❑ OUTOF-SERVICE.WNL ❑ OWMVW.AL VIA.. 500. <br /> IMITTRUCTIC <br /> US I&M-wak �:eow Nf: A <br /> M00/rNK 0OPEI11Orrom MA ILL <br /> OF MEXCAVATION %� DIA.OF CONDUCTOR CASINO Ali D <br /> DOMESTICOWYATE ❑M111VEL VACRIBQE TYPE OF CA4N018MMANC DIA.OF WELL CASINO 'i D <br /> WMICJMMNICJPAL ❑DMVEN -OEPIH OF OMOr SFAL SPECIFICATION A <br /> NSVOATIOWAO ❑OTHER GROW SEAL 0111TALW K OMUr BRAND NAME E <br /> MOMIDRDN MIDUT HEAL nNP.EO:❑Yw 13M - CONcRETEFEawALSYommot I]Yw ❑IA. S <br /> x DERV - IDOKIrID ellEdrE11 WXISIOVE PNE '! J <br /> COMEMUCr1DKMM LIMO MEMOO: MUD NOTARY AM NOTAT A1NM1 CARE OTHER <br /> T-17 <br /> HERESY CERTIFY TWT 1 HAVE PREPARED THIS,APPUCATNN AND THAT THE WOR WILL R DONE IN ACCORDANCE MATH SAM JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AMO <br /> TIONS OF TIE SAN JOAOUM COUNTY. NOW OWNER ORLICMAW AOENM SIOWTUIIE CERTR@S7W FOLLOM//10:•1 CEAMPY THAT M TNG PMSORMANCE OF THE WORK POR WACM <br /> PEI/WISYSUED,I SWLL NOT EMROY P61BM1/SUSJWTTO WONNRAN%CSMPIISATMM LAWS OPCMWOISSA' CMMWFOR'SHWMMKOCOMRACTMOSN rL CUMFtE/ <br /> FOILLOWINS: •1 CERTIFY THAT IF NO PERFORMANCE OF THE wow FOR WHICH TMS PMOAH M NNW.1 SIMI,MARW PERSONS MMJWr TO W01001i COMPMISATION LA OF <br /> AUFORMA iflE ATOAM MWr �J 2P INDULIN M 11DVAMCS FOR ALL NEM1R1®MN�ICFIDRP AT 11011{Y�Pa. COMREFE M111WINO AT W WER ARFJ1 NOVIOEL. <br /> DN.-62-'�-�f�> <br /> PLOT ING PLATHE PROKITTY. ld SaM b L <br /> 1. NAMES OF BTIQIEIH OA M,ROADIFw I/SIVE6f TD 011 SOUIlDIl10 THE PAfPERh'. {. ID EXPANSION! <br /> OF HOUSE SEWAGE DISPOSAL SYSTEIM OR PIIOPOBW <br /> . OUTUR OFTNE PRDI9RY.ONBN OREM/SIOM6 AND NORfM DSIECTIOIL EXPANBIOM OF SEWAGE DISPOSAL SYN F ON <br /> . OOAEMSIDNW OUIUNEB AND LOCATRIM Of ALL EXISTING,AID PIIDPONW B. lOCA710M OF WELLS WfIMN RAONS OF ONE MU lO!®FIFTY <br /> NUIIICTME6.INCLUDING COVOW ARDS SUCH AS PATIOS.DRIVEWAYS.AM WOKS. !i ON THE PROPMRY OR ADJOINING PRDPERTY. j <br /> a—.- .: .. <br /> MAP O N <br /> BACK <br /> :.... <br /> - k <br /> DeARIM9,r USE ONLY <br /> Aiivb sn A.WW1 BY ( ��/ AAlrl �• _ Dw. a/C�/ / � A.r !/ Cz <br /> Dwut UMe.FSFn ST o.H - n S..�Ben B;• oa: <br /> CmmnHM.:J 3 �1 !Id f tF % MiL, `/ •h!/'yGl�Yh fitf9 r>`T /I(i A' t �c �./M . <br /> d II <br /> ACCOUNTM ORT: AM FAW <br /> i <br /> FE mow 1112111" AHOUMr V&PArM K:MM RCOVW NY DATE "W"N91VICE REOUEsf RM.VMI INVOM <br /> 3 8ff. 4, ODI Rclay ItL1a a �T Ol�328 ` <br />