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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN•JOAOUEN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEM AVE'IJM STOCKTOK CA 96Z -3W <br /> (209►488.5420 <br /> i <br /> Nol-OaLIDABti rESEIET EEPIIIE3 1 MEAN LUPIN PATe lid <br /> muspi-IN TTliaBNW <br /> AFFIXATION MI H EFEBY MADE TO THE SAN JOAMM COUNTY FON A"IMM TO CONSTRUCTANCA11 INSTALL THE WOIBL DESCIMID.THIN MRICATIOM MI MALL M CMKIAF CEBURN SAN <br /> JOAOUIN COUNTY OEVULOPAHIT TITLE.CHAPTER 9-1110.3 AND THE BTANVARDN OF BAN JOAQLAN COUNTY FUBUC HEALTH SERVICES.ENVNIOMMENFAL HEALTH ORVRNIIN. <br /> / <br /> JOB ADOREBSROR AFNR�OOC.�s�Ca�_ it /ITIS...�l�f.�1S' lic Q��_CTFY JTM_1.�40M/ LOOT <br /> OWNER'S.NMF,i Ay,t _%�/(jt",:63 ADORERS ��L/ AIDNEL6.2 �T��lf <br /> BUN CONTRACTOR AD01Oy U- pROfE <br /> TV"OF REPRO WRNBR: NEW INSTALLATION 13 NSABUry0 — o"TRSRMIM 1] <br /> IID SEPTIC SYSTEM PERWITTEDV PUBLIC SEINER IS AVARABLE YYITM 200 PEET OF MNLONO.I FSRO Tunics T I EOM/MANY <br /> AI,PN�IIn, <br /> NHSTALLAMON VNIL Se1vEI RESIDENCE D CVMMFJKuL D OTHER E] <br /> NUMBER OF UVINO tNwM_.29,:._NUNwillit AF 111131100BY: 00- B UMM OF NMROYRiS: <br /> CHARACTER OF SOR TO A DEPTH OF33FEET:,, bo PRTNBOR R CHARACTER, WATER TABLE DEPTH <br /> IS S <br /> SSF'M TARKANWASE TRTTPEWFO_ 4 G CAPACITY OGY S' NO.COMPARIVAMTS IC� <br /> PKO TIRATMENT FLANF 13 ONTANCE TO MNAEBT: WELL FDUNDATION TRROF[RTY LINE <br /> i <br /> . UFT STAROM E7 EN'S TYPE OF PJMP BARO OR SEPARATOR IENCUOBEO SVBTPLR <br /> LOACHOM LIMN E7 NG.B LDFGTH OF umcS_ DISTANCE Tri NEAFEST:WELL FOUFAAT)DIN PROFWV LlIE - <br /> FILTER SUB 0 KNDTN LENOTH OEI'TH DISTANCE TO NEAIEBF:WFLL_POUHDATLOM PROPERTY UNE . <br /> MOMNIN D E7 WIDTH LENGTH _DEME DISTANCE TO NEAREST,%MLL_FOUMATPON PROPERTY LNIE <br /> SISFAm PRN ❑OEPFN SITE NWASEFL_DISTANCE TO HEAMST:VWLL POIMDATLOFI PROPERTY UNE <br /> BUMPS Cl WIDrN LEHOTH DEFFH ourANCE TO HEAIEsr:WELL POUNDALTLON PROPERTY LMC <br /> OMPOSAL FORM (1 WWHD QHOTH W P. DISTANCE TO NEAAEST,VYM_FOLNIDATION PROPERTY UNE <br /> 110MAY CERTIFY THAT I HAVE PREPARED THIS AFPLICATIVN AND THAT THE WOW NRL BE DONE M AICCO GANU WITH SAN JOAQUIN COUNTY ORv0uA10EM NO STATE LAWS,AND FLUB <br /> AND REOULATIONB OF THE SAW JOADLRN CORD -HONE OMMERORLICENNEO A4EHT'9 SIGNATURE CERTNIES THE FOILOWINO:-10ElTTETTRAT IN THE PEFOMANCEOF THE WOMFORWHNCH <br /> TNI/PENAT IB MOWED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AA TO DECOR SUBJECT TO WORKMAN'S COWPEIBArNM LAWN OF CALIFORNIA.' CONTRACTORS NNINNG OR <br /> SUN-COMRACTNO SONATURE cPJRNTEs THE fouowtmO:T CETITIPY THAT IN THE FavoFSBANCE OF TME WORN(POR MRCS THIS PONINF m IBSUEE1 SKILL SMMOY PERSONS SUB/ECT TO <br /> WORRMIANYS CdAp SATION)AVS OF CALIFORRIA.' THE APPLICANT MUST CALL 2S M04JRD IN ADVANCE PORI ALL ISORAM I ISM110 N. COMPLETE OFMAM NG BELOW. <br /> Stamm TI TITLE• - DATE•. <br /> PLOT PLAN STRAW TO SCALE)SCALE •Hs <br /> 1.NAWES OF STREETS OR MOADB FNAIEBT TO OR SD WN1INO THE pnorERRY. a.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOOM <br /> 2.DUTUNE OF THE"MPERTV,METH DORMOONB AND MOUTH DS!'CTIOH. KXPANGGN OF BLWAON RN FONAL NYSTEIAS. <br /> G.ONAMpON M OUTLINES AND LOCATION OF ALL EIfISTINO AND FROPONED STNUCTIMBLN, N.LOCATEH OP WELLSHRINN MDIUN OP OLE ffJMIND rWrV A,ON <br /> INCLUDING COVERED AREAS BVCM AN PATIOS.DRIVEWAYS,AND WALKS, THE MROPERY ON ADJONO G PROPERTY. <br /> .. - <br /> ox <br /> a <br /> ' 8 n guTM <br /> .� <br /> ENVIf1ON. N L-I�El1L'IFI ONiSlUn::.... <br /> ....:....moo ,. . :... ....._...... ....:. .:...........� . ..�.�.��/.. ,_, <br /> .-,. .s9- �.: '� _�P�✓�.... <br /> so <br /> FOR DETANTMENT U"ONLY <br /> APRLHCATION we wrm Nr! - ...� DATE: AEA: <br /> TAN[.PT OR fit"INBPTCTIVM'BY DATE r I FINAL INSPECTION BY DATE..7 7sZf !/I <br /> ADDITIONAL COMPIENTB: <br /> ACCOUNTING ONLY: ASA FAC/ <br /> me <br /> Obe FEE two AMOUNT newun HEC ASH 1ECOYEo BY DATE SII I PEPIST NUMBER NFVDICE P <br /> 02 to c, S "3Ds$ L163�4i <br /> 3 <br />