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f\ APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �W 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468.3420 <br /> NUN REFUNDABLE PERMR EXPIRES 1 YEAR FRDM BATE ISSUED <br /> r lGmpW%in TrYikawl <br /> AAFtDATION IB MNLY M40E TO THE SAN. AOU1N COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WmR DESCRIBED.THIS APMJCATION IB MADE IN COMPLIANCE W Fl DAN <br /> ,.A.,.COUNTY TRUSU O T �9.1110,3 AND TXE RPNDA"OF SAN JOAONH COUNTY RIBUC HEALTH SUURDI6,wVIPOMMENTAL HEALTH m MORD", <br /> l / <br /> ISEADS ,wNT �=c�Ka— ,"hu��NT.4,�% 'w''� n.�J cm '/'"g4J WIRES <br /> DWNER.NME /)Al ALG•L 00 we PmNE <br /> ..NTwES.. /AAEZ4AfL SPo fIC 9F.SCJw AOOREse /%N <br /> Bu coxrMnoR AODHSe VCF PXONE <br /> TYPE s.wo.e xEYJ MEr RES.... E4 ovETRwTFox❑ <br /> r' 0106 SAFETIES FES.IF FUUJD SDNER MAVAEAeM..E.FEET OF euuMNol Fx Term1IHow MANY <br /> A.rwM F <br /> INSTAYATMx wW SwVM RESSER ypy coMLEEl4:lu❑ OT..0 <br /> xlwa a uYIND RmEE: IF xLNAEEI a emwaNEE: ell NpN>•a OF wNLoreA: <br /> s CHANTER OF qR TO A OEFTN OFO FHT: -ML I MTAl1El60LLONAMCTM WATER TISSUE!OEPrN <br /> TAM.TAMIRAF ❑TYTFMErO LJrUC C c:APpcm /E.Ot) RO.cOMPARIMENTE 'Z <br /> PpO TWTMwT MHTO WTANCE TO MWHI: WELL TOVrRATNIN S E SOPEMYILE <br /> NFr STATION❑ SERF TSve OF PU. BAHT O4 EEPAMTOR 6SlL..SYSfMI � <br /> IFACMxO USNE /CYTI INSTANCE TO NEARER:WEl1 /G•x'JI FOUNDATIUS—Ze— iII'Y LINE <br /> r NIT.Sm O WRTH LLMOTX DEOFFH_INSTANCE TO NF ST:V M1 FOUNOATDN PROPERTY USE <br /> NOVNOd OWarM EFM6TH SEIDISTANCE TO NEAREST:WELL FOUNDATION PMREETY UNE <br /> pFAAOE RT. OOEPIN SEEE NUMBER pIFF..F TO NEAREST:WELL_FOVNWTDN�PRoPEMY ISIF <br /> pLMA 13. LENGTH DEFF._INSTANCE TO HFASEST:WELL FOUNDAPDN�PROPERTY UNE <br /> r UNOSK Ell.. DUENTH DEPTH DISTANCE TO NEAREST!WELL FOUNDAPON_NNUDRFTY TINE <br /> I HERSEY CMRIIY THAT 1 HAVE PP£PARED THIS AFRUCATIOH AND THAT THE w9P(WILL UE GONE IN ACCDMANCE WOH SAN JOAOUIN COUNTY ORDIHANCEB AND STATE AW6.AND RMES <br /> AND REOVLA1mI®OF THE BM JOADWN C01Mry,HOME OPMEA OR USENBED AOEM'8 SRNATURE DEFORMS THE FOLLOWNO:'ICEMIFYTHAT IN THE PERFORMANCE OF THE WOE(RDIIYMCH <br /> MS PEIORT 18 REFUSED,l SHALL NOT EMPLOY ANY PENRON m EUCH A MANNER AS TO BECOME WBJE4Tr0 WOR(MDI'B COIMRNSATIOM LAWS OF CAllIO1NIA.' COMRAMORS RNSNO OR <br /> 5U-iOMMCTINONONATU, CEMIFIESTMFOLLOWING:TCERT IFY TXAT mTHE RIPORMANCE OF TME WOP(POR WMLN TNIB PERMR IB ISSUED.I N1NL ENERGY FFRWNS eVe1ECTT0 <br /> PxMwx'8<oMPENBATpN UWB CALIFORNIA' TIEAPRICMT MUST CALL 24 HDM6 IN ADVANCE PORALLREOWm INSEECPOHS. COMPIFIE CRM1WINO BELOW. <br /> DISHED S 10L—� TRUE ULXI Ny GATE' <br /> PIOT PIAN OMAN TO SCAI£I ECAIE <br /> x M1E8 OF STREETS OR WP08 NEAREST TO OR eOVNdNO TNE pIm1ERry. I04.LOCAT WM OF HOUSE HAAAOE MS196K SYSTEM OR EROFOBMI <br /> ].OVTUNE OF TNS Wg44 .WIiH OIMENBmHB AHD NORFN OINCTRN, EMPMJBMN OF SEWAGE DHFOBµEYS .. <br /> OIMENSONEO OUTUNFB AND LOCATION OF ALL EXISTING AND FImPoSED STRUCTURED, S. LOCATION OF WELL6 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SVC.AS PATmS OPIVEN/AVS.AND WALK.. SHE FREI OR AO,..No PRPERTI'. <br /> {L <br /> \0 <br /> , <br /> SIFS !vr <br /> J <br /> I J.. <br /> V IGS <br /> r _.ftp/ $All JD^0 ARV'R 1 T: <br /> I UCLIr YI I ACF& <br /> 9J:iIP {"I4i .+6:IY ITIWISP:r.. <br /> ,F Tr� . 1y,� p TmwT USE ONLY <br /> MPICATKIN ACCERFD eY v' E 1 C `�' DATE: S 7 APF A: ' <br /> TAIR.NT OR BUMP MKPECTION BY DATE I I EMAL IN.PELTION BY DATE ,O <br /> AOOTIOxµC V MMEM6-. <br /> Aee...SN.oNET. W04 <br /> G�II F�/✓ AMO�� ITEO ITEC I/ADN RFCEVm BYE � SMIIBTYTNIMr1BM1,/ NVDICEI <br /> � 9 <br /> 'rub.Health SEIv..Enwa.174(9196) PLATE 9 <br />