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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,445 N.SAN JOAQUIN ST,STOCKTON,CA 95201-MBS <br /> (2891 4583420 <br /> NOMREFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> rGmpIBM IN T,*rt i <br /> KPIICATION IB XFPPBY MADE TO Tf1E SAN JOAOUW NWTY FPR A PFPAUT TO CONSTRUCTANDMB WSTNL THEW DEWRIEED. TNK AFRMATION IB MApE WCOMRIANCEH1T11 B.W <br /> JOAOUIN COIIMY DEYEEPRAEM TTTY4 CXAPTDq{}1110.3 Mp THE LYANpANpb OP SAN JOApVIN COUHTV W 9UC MGLTNr6OWK'E8.FIMPoNMFI-TLL HEALTH OMH]N. 1,T <br /> -a ADOPFasMR Aw/M� � O �U t � N'uA Y I�/�D( Tom' c". 1'SL DI D/1 I^ST fi¢Eyy,��1� <br /> OWNERS NAME QI OG(YYlg F4 fir ADDRESS LT.to(do ITT �"iWll I�.C.J PNONE�S�`_T <br /> CONTRACTOR iAA )4L F;A H.cC ADCIE85 ILiDX (R 5D uct PMoNE' -n 11 <br /> WE COxrRNnOR ADDRESS ucr PlgflE <br /> TYPE OF BEPOC WORK: Now NMTAUAYoN❑ IIfTANfAOOIIIOX m rT oN❑ <br /> OM SPfC EYETEM PENNU TED IF MEIN.8INYEN 18 AVMABtE WRHIN 20)FET OF WIIDWG.1 PER=TWBN(I HDW N M <br /> AppMNn t <br /> WPTN 71001 WILL BaRM. RV1ADENCEfY COMMERCML❑ OTHER r3NV. BF YVMO YINIB:1 NLMt910f aEtl10pAE:_��XIAiBIOPWND. <br /> CNARACTFA DF 6ql TD A OFPM DF O FEET: PLd PR=w BOB CNMAGTER: WATER TMIE DEITN <br /> BFIIC TAHN/aoKNeE TNM ❑TYFFMfO =APACrtY ND.COMPARfMENTE _Q'1 <br /> wo: I YMENT PG.NTO pYTANCE TO NGNBBT: WELLFOWOATION PRDIEMY LINE <br /> IFT STATION 11 RW,�E TYR Of FV MP BMD OB BEPAMTOR RIICWBED BYBTENR� �.�'� <br /> IEACNNO INF RO ND.LIEIN3TN OF WEB IL;r; F p6TANCE TO NFMEeT:WELL yyy_FOVMOATgN�fj_PMPfRfYl1NE �aO� <br /> FILTER ELD DYADTX LFNOTX DEP&—OKTANCE M NEAREST:WELL FOUND N_MPERTV UNE <br /> MOUNDED ❑T.WIDTH UN. ...IE TD NEAFEST:,4 M. <br /> PRORAIY YNE��� <br /> G®A¢PRi c OEPTHi6� 41 KkNUMpEATDIBGN=ETONEMEBT:WELL L n+FWXWTgNJy�PIOFERIY WIE I7lDT Z. <br /> MINi'i ❑WIDTH Lo-orN DEPTH DKTANCE TO NEAREST:WET_FOUNDATION RIO.WE <br /> DYPOGL MR" 13 worm LENGTH DEPTHOBTANCETO F$ARFST:W91 TOUNDATON PROPERLY{NZ <br /> I XE 23Y GENTRY THAT I HAVE PMAIEp TMS AflRR=N MD TNAT THE WONL WRL BE LONE IN AWOROMCE WRN lh i JOAMIN COUNTY ORDF N B MO STATE SVA.MO WRE6 N <br /> M REDDIA ON6 OFTW.JOAWIM COON Y,MOMEOWwptORUCEXEFONifM'861ONATVRE CENTRES TWFOLLOt G:'I CERTIFYTHAT INTHEFFl1FONANICEOFTXE NOIKFOflWMCM O <br /> TNIe P9iM KIS6UFD,IMIALL NOT EMRDY ANY FER90NWeUCNA1MNNE0.A6 TO EEWME WRIECT TO WpIKMM'B COMf4N8ATpN lAW80F CPIFIXMA:WNTML WSNWNGM <br /> 6VECOgGCTNG MAYOR CERTIFIESTM f040yWND:'ICpTFYTNAT N TME AFAfOW.1NKE OF THE WpR FORWHICH T B PFN10T 181NUED,I e EMFU)Y PERSONS WRQ M <br /> WON(MM9COMK'N�GT,(O�EN_,(G/IW80G CNJFpfWA11A�' T//H/E AfOIK�NNTMWiCALLbHOLpi NAOVMCE ION A/LLN[OWIEO IXLPJBTWNB. COMFlEtECMWINO EFID//Wf' (J/Q/ ' <br /> SIGNED Uv v"✓ i� /LL(/�� TTTF: LJ.Dl1/I fcGTJr oATE:_��i/� 11J <br /> r <br /> PIAT RAN(pMW TO BCµ£)8CALE <br /> 1.XM1ES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PMPFRTY. Na.LOCATOM Of XWSE BfWASE 016WOAL BW'TPM Oq gq{ODfD <br /> 2.OU OF THE POFFRTY.WITH MNUENtOw MD WRTN pAE=N,N. EXPANSION OF SEWAGE OlelOeM SYSTEMS. <br /> i.NNEHN oOMUNEE MD WCA N OF NI.ERI AI.V PROMDED GTRIJ NES, <br /> .. 6.IAC ...'YIELLi NTTNNRADM80PONENUKVRDRFT'FT.ON <br /> NCWDNO COVERED ARFA6 SUCH M PAT N6,M.AYS,MO WA $ THE PROPERTY OR AOOINIW PROPERTY. <br /> ul. a ..... �..:.... <br /> (dof ppb' ��L'ox <br /> Lee <br /> �:^ O <br /> z y _40T <br /> o JAN 18 i996 <br /> GOR OVMTMFNT UFE ONLY VIi II.'v. ./ ..,.HL':•'TY T:I',...Q(,{T �� <br /> APPJCATON TCCFPTED BY DATE: C APFA: O <br /> TM PIT OR BUMP NSTECTON BY DATE <br /> � /�l I t �FNKINePETON BY O WTE � )��/ �IFJ <br /> ApOTIONM M <br /> COMMEB: P/WJzIe <br /> • MCOUXTNO OMLY: NO+ FAG L <br /> DECODE FFL IMFO NApONT PFlATTm CMS MABM pggy®EY DATE N! N iMVOgE1 <br /> 0 O 54' 3 <br />