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APPLICATION FOR LIQUID WASTE PERMIT SyD 'is�, /� �AN JOAOUIN COUNTY PUBLIC HEAL� M ERVICES LTH DIVISON 304 EAST WEBER AVENUE,ENVIRONMENTAL STOCKTON, CA 95202 SEPTir; ` (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r1mopItM In Trippnu) APPLICATION IS HEREBY MADE TO THE SAN"AWN COUNTY FOR A PEWIT TO CONSTRUCT ANDMR INSTALL THE W W DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH SAN bAWINCOUNTYDEVELOME ZZLLCHAPrERS-111�STAN S AN JOAOUIN COUNTY WBUC HEALTH S�ERVg988.E_WIIONMEWAL HEALTH DIVISION. �//p� JOB ADDRESB/OR AF t)1/W�/`(')� ` /,�,�� CITY �Tt', -V ,C'� LOT SQ`/&V ' OWNER'S NAME `C' T-'av /' � , ADDRESS_ �":T`�-�. PHONE L1012) J _/�O PHONE COWMCTOR M\ / `�•� O AMS8 sue CONTMCTM . `�'� % "��1-""C... . ADORES. T'P[W GERM WORK: NEW NSTALIJ!M R"AIIVADOIMN 13OFSTRUOTION 13U SEWER NO MOM We"PERMITTED IF PR 18 AVALANE WREN 200 FEET OF BUILDING.) PMIC MITI)I 1 HOW MANY y APPMSSB I MOTH TION WILLS . RESOENCEkC,COm&mERc AL❑ OTHER E3 (' POSSME%OF WINO LISTS: SIMMER OF SHDRGGMS: NESNSEI GF WPMLO — _7 OUASAwFFN TGTw DF 3❑ ^ C c �PITISUMP SOILC CNAMCTER: WATER TABUDEPTH TPIKE TMMTMTMBET�KAMT❑ DISTANCETTOFFMELF�SO.TT: ELLeD� MUNDAMIN PROFERTYLINE li'e% LOT STAMM❑ SEE TYPE OF PUMP�Y1 BANG OIL SEPARATOR ENCLOSED SYSTEM - LEACNWG ME •S MORTEN OF UVEB�`I I I /L"�'L.JZIeTANCE TO NEAREET:WEU(:QK2 T FOUNDATION S PROPERTY UNE C r FILTER SED ❑WIDTH LENGTH DEPTH MFEANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BOUNDED 13 WIDEN LENGTX DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE NTS ❑DEPTH SDE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIUTEI LENGTH DEPTH DISTANCE TO NEAREST:WELLMUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 094WNE INA ORDANCE WITH SAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANO FEOy TIONS OFTNE SAN JOAWIN COUNTY.NOMEOWNEROfl UCEN8E0 AGENT'S GNAT CE IFIESTN POLLOWNG:'ICERTIFVTXAT INTHE PERPOWANCE OF THE WORK PORWIIICH THIS PEWIT I IS D,1 tll NOT EM0.0Y AVIV PERSON M SUCH A MANNEfl AB TOCOME SPEC TO WO MM'S COMPENSATION PAWS OF CALFORNIA.' COWMCTOR'S HIRING OR SUBLONT NATU ERTIFIEB THE FOLLOWING:'I CERTIFY THAT IN THE{'�160RAIAN E OF E WO FOR WHICH THIS FEPMR M ISSUED,1 MNL EM0.0Y PERSONS BUelECi TO WOFKMAN'S CO N ATION WB OF LPO T'�r..`.J.uCAMs-MUST CALL FIOU1t IN OVAR ALL RfOUDIPO INSPECTIONS. COMRETE DIIAVANO BELOW. BIONEQ% TRIP: OATF.�o �� ROT RAN IDMW TO BCMEI BLA(E 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OWUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. j: I \ 1 No -S i I I _ OL/7s o 4 „ ,sot. APR 8 X991 A-� APRICATION ACCEPTED RV �%%%'''�� IrA A DEPARTMENT USE ONLY Q \ 'ICY V ySD GATE: TANK.PIT OR SUMP INSPECTION BY \\- DATE / / FINAL INSPECTION BY DATE /Z/ ADDITIONAL COMMENTS:� � lM fRO/�,{ WC-1 LS 6W $/ l /06" ON {V&w tL 4 Al ACCOUNTING ONLY: Ly N FAC# rt CODE FEE INFO AMOUNT REM I TED CIIEC /CASH RECEIVED BY DATE SR/P9MITNLMBEH INVOICE• S -) 3 Pub.HeBHD SeN -Envvo. 174(3/96)