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L _-- �►—'----- — - -_ APPLICATION FOR LIQUID YIIE/I E PERMIT -- -_--_--- <br /> ' SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> j P.O.BOX SBS,SOt EAST WEBER AVENUE,STOCKTON,CA 9580/300 <br /> (205)4883420 <br /> NON-REFUNDABLE PERMIT EXPIRES E YEAR FROM BITE ISSUED <br /> (CFMPMM In TrIplkFbl <br /> APPLICATION IS HERESY MADE TO THE SAN MAWIN COUNTY FORA PERMIT TO CONSTRUCT AND..INSTALL THE MAR DIECNOED, TNy AgLCATION In MADf d COMRIANCF WIIM FAN <br /> JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 0-1110.3 A THE SSTAANDAROB OF GN AAWIN COUNT'NBLyM HEAL"SERVICES,ENVIRONMENTAL HEALTH OIW BON. �{ <br /> MS ADDRESSgR AMPS �., �:�Il' 01441 81**T 1�I -y,5l i.l1�`{UF�)AA 11-1 ESE-,T, �5 Tic II 111.jT�- WINES M <br /> O.ERR NAME !:)I-I iE. '�'IIJE T- ADORER,/ 1VEJ rll (X9'/'L Cl &VE) )AI{"A'1( r/(- •-"/57 PHONE <br /> c.NT%AcroR/'!' fkIr ;m,) 1 A,-iUC (AJC ADDREen 2.2 XJ /{5V'7M L/J ( n01 4S�oLroFnh%gnl� PNDNE'3F 7 <br /> LI SUS CONTRACTOR ADWell LIC' MNMN <br /> TYPE OF/EP IC WORK: NIMPROTRuAr.ko Rp4NAIREmN O DESTRUCTION❑ / \ <br /> IAO SEPT.SYSTEM NFLITTEO IF P"NA SEWER IS AVAIGBUE WITHIN 200 FEET Of SUIUMG I FLIM TN119I 1 I HOW MANY l / <br /> NEgen• <br /> INTAWTION WILLSgV[: pE61DENCF❑ COMM[ROIALo OTNFfl 0 <br /> MUM"OF'V"'URN:- NLM/q OF FEMOOM/: MUN M EMPLOYEE, <br /> CHARACTER OF SOIL TO A DEPTH OF O MOST: WISUMP SOIL CHARAMR: WATERTASUE MRN ��n <br /> MOTH TANSMPGFE TRAP ❑TYKMFO CAPACT' W.COMPARTMFMt <br /> V MSO TRG1MgT MART O DISTANCE TO NEMERT: WELL FOUNDATION PROPERTYum <br /> UFT STATION O SIZE TYPE OF NMP MND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LGCNNLTER E Ux[ ❑ NO.\LENGTH OF UNNT DISTANCE TO NFARFM:WELL FOUNOAMN�M%,MMTyUNE <br /> ROUNOM 13 Or" LFNOTX pERN_�dSTANCF TO NEAREST:WFIL iOUNMTON�HpPERTV UNE <br /> ` MOUMOFO 13 MOTH LENGTH pERH�DISTANCE TO NEAKR:MR, FOUNDATION.PROPERTY UNE <br /> ---.E MT/ ❑OFPTII M2F NUM.6 DISTANCE TO NEAREST:MIA iOUNOATONNORIT'VHF <br /> MAIF/ O LNDTN LENGTH DEPTH-DISTANCE TO NEAREST:MUM. FOUNDATION�MOIEMry UNF <br /> L OISPoML POND/ ❑WIDTH LENGTH pERN-DISTANCE TO NEAREST:WFLL- <br /> �FOUNDATION PIOPEM UNE <br /> 1"EMERY CFIRIry THAT 1 HAVE RIEPApFO iHle AplOAT 0.AND THAT THE NCML WILL SE DON[IN MCOROANCE WTTN SM JOAOUIN COVNTV OMMMCG ANp RATE GWS,MO U. <br /> ANO RFOVGTON.OF THE SM JOAWN COUNTY.NOME ONMER M VCENSEp AOEHT'S SIONATUM CERTIFIESTHE POLLOW W 'I CETIFYTHATMTHEPEMOWANCEOF TNENCIKIOM.WI <br /> THIS PEW R M ISSUED,l WALL WT FMMOI AHV PERSON IN NCR A MANNER AS TO SFCDME IUSJECT TO N MtMM'S COMPENSATION UNH OF CAUFOMIA.- OOMMCTOR't HO NO OR <br /> SUS{ONTMCTINO SIONATUIE CEFTNIN THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR MUCH THIS PFRMR,.ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WOPRMM'6COMPUNSRION{Ayt��AUfOp11A' TH[APPUCMT MUST CALL NNOW IM <br /> AOV'NF011LLMFOyR''1pIFCTON/ COMPLETE [NO SE2WW. <br /> SIGNED � PP � <br /> f PLOT MN IDMW TO BCAUD KALE -b <br /> 1. NAMES OF STREETS OM MADE NEAREST TO OR BOUNDEN.THE MOPEMrY, A.LOCATION OF HOUSE SAVAGE dSPoSA SYSTEM OR P CPoSED <br /> S.OUTLINE OF THE P OMEM..WRH DIMENSIONS AND NORTH DIRECTION. EXPMSION OF SEWAGE dtgeAL WITTEN , <br /> !. MMENEIONED OUTLINES AND LOCATION OP AL E%IRMO AND MOPoBED STRUCTURES, E. LOCATION OF WFLLB MTHIN RADIUS OF ONE HUNDRED FIST/n,ON <br /> MCLVdNO COVERED AREA.BUCN AE PATIO.,OWVEVlAY8.AND W IJAE. THE PWPE"OR ADAIMNO MGPERry, <br /> T--- ��A�il �•� - IV <br /> SEE <br /> iJ <br /> PAY NhFraT <br /> I <br /> NEE _. "ECF'rVHJ I > 1 -4- <br /> DEC 71999 <br /> -J • <br /> ENVIPRUBITN <br /> ONM"'ITM HEAITL,ICES <br /> OIVIS,ry <br /> EES <br /> ` <br /> if <br /> B. <br /> 1 ( T �...�FO�R/O�.�A(P-r}-���'N.T......Y DATE: AMA - <br /> 6. <br /> t APPLICATION ACCFREO BY IL�e��LU 1 �WV�A'-'\�I I�I � A. �/C}� <br /> TAMC,SOT OR SUMP INSPECTION SV DATE I I RNAINSRCTION.Y DATE <br /> AODUIONAL COMMENTS: <br /> ACCOVNTINO ONLY MpI AACF <br /> PF CODE FEE INF. AMOUNT RMITTEO ALICE WICASN RECOVED.V DATE y11PNA11TNU1A/q INVOICE' <br />