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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> .~ (209)468-3420 <br /> NUMBIFRDARLE FFRRIT EXPIRES I YEAR FROM DATE ISSg <br /> j (CamFheF h TrlpRnu} <br /> AFFMATION IN NETUBYMAOt TO THE E.w.pADWiN COIATTYPOR A FNR1fr To CaktrRUCr ANMVOfk WSrALL THE Wont DESC 0.TMS AMMATION <br /> i F LAOEnCOMRIA <br /> RE WTH am <br /> JDAOL N COUKrY OEViLOPMNT TRLL CLAPTER 0.1110,3 ANDY PTSC HEALTH ve"YwEs pildww" m MALTH OrAmm. <br /> JOBAOOHEYOMRANP R <br /> W7 YIEF- <br /> OWNER'S NAME SS PHONE <br /> CONTRACTOR ADBI�YB T � - Me <br /> SUecONTRACTOR _ ADDRESN IICf PHOHE <br /> Tim or Berm WORN: NEW INSTAL ADON❑ P"PDVADmTION[� DFa7RUCTro <br /> M MIFM SYSTEM PDRGTTEO IF InJELOC SEWER 16 AVARASLE MrMN 200 FEET OF SIIRONGJ' � FM TESTN7 1 J HOW MARY <br /> P*da•e�+1 f� <br /> tNSTALtA,T10IY VaLL SDlvc n:EORJCE❑ COMMEICUIL❑ OTHER❑ - <br /> NURmFTI OF LLVNG UNITE: NW69t W S®RDOMS: NIsmI91 OP INPLOT6E: . <br /> CHARWIn OP SIX TO A DEPTH OP!FEET– 'ATKWEP 800.CHARACTER:" WATER TABLE bEPT L_ <br /> SUMO TANRIOI SAFE TRAP ❑TYPFJMF.7 CAPACITY NO.COMPAR"ADJTS - <br /> PRo TREATMENT RUNT❑ DISTANCE TO NfA11deT: WELL FoIMDATgN INIGFERTY UNE <br /> NFF STATIOIT❑ =ZF TYPE OF PRIMP BAND OIL ETPARATUR MWLOSED OVI1TE1611 !, . <br /> UmHWG LINE 13 NO.S LENGTH OF LINES— bISTAME TO NEAREST:WELLFOUNOA7ION PROPER7YLINE <br /> FILTER BID 13 WIDTH LENGTH OEP?H bIYTANCE To NEAREST:VAU.PDWeATIDN FROPERTYLOW <br /> mounaED ❑riTDrI LnmTm_DwnN DISTANCE TO NEAmn:WELL POUNDATSNI PROPERY UNE <br /> SWAM Wfd 13 DEMBRE NWAeER DnTANCE To MAIEST:WELL 'VOUMIATION PROPERTY LPA <br /> i SOIA►S E3 ww11 LENGTH_ NC <br /> no" OISTAETO HEmmn WELL _ _rotmDATm mmmnm—it� <br /> mmmm r1TPms CJ WIORH LEPIOTH BEPTH MTANCE TO WARE VAL Il MVNAATIOTI P7oPERFY,WE <br /> i mEMSY CERTIFY THAT 1 HAVE MWARED THIS APPLICATION AND THAT THE WONT NKL BE GONE LH ACCOADAME MOTH SAN JOAOWN COWRY ORDIRMR.Ce AND STATE LAWS.AM Mug <br /> ANO7IE9ULATTONS OF TILE SAN JOAauwocOUHTY.How OWNDIORUCum"AQEN7•S SIONATUVi CERTIFIESTHETOLLOEYa1O;4 CERlIVYTHATN THEMINFORMAICEOF THEVINOM rOAMWA <br /> THIS PE1q.OT IS Itmsp.I SHALL NOT EMPLOT ANY Fp1eaN IN SUCH A FANNER AS TO BECOME was MrTo WOW MAN'S COMP049ATIoN LAWS OF CALROIOAA! GONTRACTOICB I wam OR <br /> StmCONTRYWT4111 SMATURE CERTIFIES THC FOLLOYWNO:'I THAT W T1LF PERFORMANICf OF THE WOW FOOL WNICH TMS PLRYYT M MMM,1 E11All EMPLOY TO <br /> WORKMAN'S COY EWll',AL"RNt&.'TINE A111NPC MAT GAL 24 HOUNC <br /> INS IN ADVANCE FOR AU NDSLSRND 0111MITTONS•E0AIRE7EDMYYNO <br /> SgNEO X 'Tm.. L _, DATE: <br /> PLOT R.AN MRAW TO 41CALEI OGEE 'W <br /> 1-NAMES OF STREETS OR ROADS NEAREST TO OR S MANNINPROPERTY. <br /> G THE 4,LDCArMw OF HOUSE SEWAGE OI <br /> St4DSAL SYSTEM 011 PRDI+OiED <br /> T-ourLwE OF THE RIOIERTY.v.TrH LnAEN81ONS ANO NoRm DIRECTION. EXPANSION OF SEWAGE OtWORAL tYNTptS, <br /> a.w4mowb OUTLINOS AND LOCATION OF ALL exwr*dG AND PROPOSED aIm.OTUAEY. E.LOCATION OFNELs VWMM P.ApMS MONS HUH016D PIFTYPT.ON <br /> INCLUDING COVERED AREAS 1VCI1 AS PATIOS.bRFAWAYS.AND WALK6. THE F"UffPrV OA AP10NAq IM PFIERTY, <br /> ....:..... ..r <br /> ' I <br /> p.. _ _ .....L..- ...... ... ... :. <br /> : . <br /> ..... ..... <br /> yL <br /> . .. ..,..�J ��. ��... ... .... ... ... <br /> i. <br /> t. .. ...4 <br /> LJ. FNTA EtZTH/?CE& <br /> ..:., .._ ._:.._... ...... .4JIbN,, ...t... .. . .. ... .:.... <br /> . <br /> .,.... ... ... .. , <br /> `—'l .�7oRj uee oNLr <br /> APPLI[ATION AGLEPrEa By ATE: <br /> I TANK,PIT ORIJ RY _ DATE I L _–FINAL NIVECT.OIA SY - DATE <br /> ADORIOHAL(. qL <br /> 6 u r- <br /> ACO011Hw"ONLYI AOI FACE <br /> re COOS FLEINFO AMo1R1T 119NH TED rs41C ASH RECOVER er' MATE <br /> Q m1 T PEONT TRWmmI IINOICEr <br /> I �O <br /> :Pub.HEeRA Serv.-EnvLm.174(9186) 1 1� - <br />