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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.C. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-0389 (209) 488.3420 ON-REFUROAILE YERNIT EX IBES 1 YEAR FROM b9TE ItIU icamw1Eb M Trklka* APFUCATOII OS WRIErF MADE TO THE SAN JOAOU`N COUNTY FOR A PERMIT TO CONSTRUCT ANDPOA INSTALL THE WOM DESCMIED. PHI/ APPLICATION Y MADE IN COMPUANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TrflE, CHAPEEA 9-1110.11 AND THE STANDMIOS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH ON ON. JOS ADDIEBB.OR A, A y'%,:rir %. o N eJ > , Rw crtY FsC A ca/y LOT SUE owNER's NAAg 804 gr5e ADma. SAlle_`—--`---RMONE�3i G 3sr CONTRACTOR_Q.Lt1E f ,L.y --v 50AI _ AODIIEBS 4W7 B1lj�a Vtj t'14/01;X uc, '/9'y YV/ naN:�. ''`1.11 �1• WB CONERACTOR ADDREBS IICP PIONS TYPE OF aVRO WOOL: NSW WtVALLATWN RQASUAME10N OOTRUcrw% Q WO WPM SYSTEM PERMFRm N PUBLIC SEWER IB AVAILABLE WETHIN 200 FEET OF SUILDING.I PVN: ipTNi I 1 NO'N MANY _ fqAPIyeAtlm INSTAWATION "LL SW.1 LASSIE Jr E W COMMERCIAL ❑ —HER ❑ ' MMaSR OF lJV1N0 WTa:___ I NLl.N6l O,,FLSEORROOIW:NWa: BIR of aRROT CHARACTER OF 000. TOA DEPTH OF 3 FEET: /lam h" PITlGUW BOIL CHAlAC EER' JAN [I WATER TAME OEPTN j -f SEPTIC TANICOPEAM TRAP ❑ TYPE,ANO CAPACITY NO. COMPAHT VENTS PRO TREATMUIT PLANT 13 DISTANCE TO VAJW V WELL E:OUNOATION FTIOPPRIY I,NE LIFT STATION ❑ ssSIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSW SYSTEM] L UNE F NO, A LENGTH OF LWEB_ J hFo' DISTANCE TO NEAAEST: WELL tLO' FOUNDATION 'EO' PPIOPOT'UNE ,y 19001 am ❑ WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST: WELL FOLINUATON PROPERTY UNE MOUND® 13 WROTH LENGM_ OEPTN DITAHCE TO NFAREIT: VAU FOIiNDAT10N PROPODY UNE SUPA4f PITS 13 DEPTH ME_ NUMBER A6TANCE TO NEAREST. WELL FJUNOATION PROPERTY LYRE GUN" X WIDTH _3 , LENGTH / X'^_ DEPTH /':P _ DISTANCE TO NEAREST: WELL /010' _ FOUNDATION fC • PROPERTY UNE DISPOSAL P"m 0 WIDTH LENGTH — DEPTH DISTANCE TO NEAIEST: VVBI __ FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PFIEPMED THIS APPLRCATION AND THAT THE WOFK WALL BE DONE IN ACCORDANCE WEEN SMI JOAOUM COUNTY ORDINANCES AND STATE LAWS. AND RULER AND REGULATIONS OPTHESAN JOAQUIN COUNTY. HONE OV~oA MENIFl3 AOENT'I SUEHATUff CM*WSTIK FOLLOYANO:YCERTOPF TTUTLATHE PEfiORMAHCE OFTHEWOW FORL ICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CAUFOBMA.* CONIRACTOR'S HIRING OR SUB.CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: -1 CMT\HAT IN THE PERFORMANCE OF THE WORK FOR WHICH TFIE PERMIT IS ISSUED, 1 SHALL "AHOY P~NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' THE APPLICANT MUST CALL 24 NOUN& IN ADVANCE FOR ALL REQLMiD 060107TONS, COMPWF ORAWIW BELOW. SONEO % d-"'__.6 _ - - - Tlllx PLOT PIAN (DRAW TO SCALL'] SCALE ,- 1. NAMES OF LTfPEETE OR PDA" N[APEBT TO OR SOUNDING THE PROPERTYLOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE Of THE PRDPFJITY, VATH DIN IENNONS AND NORTN DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBfTMS. 3. ONAf NSIONEO OUTLWES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTVFIES, E, LOCATION Of WELLS WAIN RAOOB OF ONE HUNDRED FIFTY FT ON LNCLk"M COVERED MEAS. ELI AS PATIOS, OR]VEWAYS, AND WALKS. THE PROPERTY OR ADJOINING F7OPE RTY >741 Novb,e6l hl volt R Y 0 i "o,30+ 'PAYMENT Po soft SEP 2 6 1995 :,AAi.JGA1(,1LIuV CGuE%??' PoBLIC HEALTH SERWGE 'N;l,F()`AAENT.AL. HEALTHQ!UISj �/�( --j,S POR WART MpLOUVT LONLY APPLJGATOW,'F—N ACCEPTED SKT GATE: TANK, RET OR SUMP INFAECT ION BY " GATE I I NAA, INSPECTION BV V+�t�"� RATE IR.S ADDITIONAL COAWFMS: Tl.JT� ACCOUNTTIIO ONLY. I ADP I FACE U1