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APPUCATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 ry``JJ {209)468.3420 �/7� _ NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISIDEQ E./� �;7� $Caey1EBE In Tr411atE1 AMVCATION M HEREBY MADE TO THE EAN JOAOVEr COUNTY FOR A PFFJA T TO COHSTPSICT ANO.ON NSTALL THE WORK DESCIESM-TME AFFLXATTON M MADE N CON 41ANCI WITH EAN .IDAOUPN COlAV1Y DMLOF4ENT ACNA&M/-1110.3 A,P40 TTIIII�STAkIDARD2 OF BAN MAOUAN CODNT'Y N/lJC HEALTH BEEIPACC11-/E'/MNONMENTAL NLALTH EINIEION- JOe ADDRE//NR APNF 1'. J)_ G I //•APRT y+�✓O 1`t' CrrY 3 I r'N LUT MEF 1�L ' OWFIEl1•f NAME��`P U' LT/(y� _ _AODNEea �l� FwHE coNTRACToN 1'F3' �AIIEa- i Al�� ADDRESS? N7/CONTRACTOR '-KO"'/G AOOKIG LA:F 'f11OHE TTrE OF SE7TTC WON(: N/W INETAEATION❑ AQAmAOOITION❑ OEETBI1C ttOR�I IMO ERC EYS7EM rooARTEO E PUBM MWER W AVAXABU YVrTISN 200 FEFT OF SURDINU.1 FMC TA71A11 1 NYW MANT AFPSAAMn F_ INSTALLATION WILL GI114L NEBEOENC[❑ COMMERCIAL❑ OTIIER❑ NIMBI OF LIVING UMTa: NLMM OF BROOMS: NUAfM OF RAPLOY : CHARACTER Of SOIL TO A DEPTH OF MT: FTr/ P SOIL C/NMI-CTFWATER TABLE DFPT11 - SEPTIC TAPRUOIETRAP0 ASE TTYFEmM1ME'f CAPACITY NO,COLIPARE14IPRS Ma TRIATMMT PLANT❑ W TANCT TO NFAMM: WELLFOUNDATION PROPERTY ENE AFT STATGN❑ NZE TYPE OF PUMP /AND OIL SEPARATOR IENCLOMO WMMKII uGD NNG uNf ❑ NO.S LFNOIH OF LINER OISTANCE TO NEAREST:WQL FOURL'ATION MAOFERTY LK FILTH Em ❑WIDTH LENOTN DEPTH DISTANCE TO NFAFE(E:WELL FOUNDATION PROPERTY RIE MOIIDSD ❑YRITrH LENGTH__CERN DISTANCE TO NEAREST:WELLFCANOATION PROPERTY LP/E 090PA01 RTa ❑DEPTH WE WNKA DISTANCE TO NEAREST:WTAA —H OATPOM PROPETRY LNW SLEIS►E ❑WIDTH LMrH _DEPTH UMANCE To NEAREST:WRL FOUNDATION HIOFq rTY LINE DISPOSAL FORM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAIEIF:WELL__FOUFAATTON FROPORY LINE I HEFESY CERTTY THAT 1 HAVE PIEPAIED TMS Ar ATION AND THAT THE WORE.WILL K DONE N ACCORDANCE WITH SNI IOAOLMN COUNTY OTOIANCES AID STATI LAWI,ANO IIUIES AND FIFOLAATIONS OF THE SAN.ROAOM COUNTY.NOME OWNER OA LKEHEm AGENT'S OW"rLWE CIRfolts THE F0410'NNO:'1 CERTIFYTHAT LATHE FEIEOMANCE OF TLE WOM fOR WNCH THO rOENr IS AWED,1 MAL NOT EMPLO POISON N SIPCII A MMaNER N TO EECOSF[EU/.IECT TF1 WOIE(YATI7 COMFENMTION RAW/OF CALlOFSAA.'CONTMCTOR7 NSR!OR WS{ONTMCTIIq ROIIAT111E CORPSE [REIFY THAI'NTN[pOEp1EAANC[OF THE WORE(P01(1�1ICM THE N'IEAIT H IESVLE/.I SIU1lt EPAPLDY rERSONS EIUB•EC7 TO WORRALAI'S COOU%FMATION OF C NBA.- THI AR CANT MUST CALL M NOW N ADVARCE FOR ALL RE}Illm INEMCTIONS.OONPLM OTUYYNS SfiOW. /yJ r SIGNED X TITLE: I I /r.(��i\ DATE: / ` ROT ffAN DRAW TO SCAM SCALE m 1.NAMES OF 9TWTTE OR MAPS NEAREST TO OR SOUMOINO M PROPERTY. 4.LOCATION OF HOOK KWAGE OIlOSAL SYETEN OR FFOPOSED 2.Okff UNF OF TM Pr0/flRY.WRH DININMD-ANO NORTH DIRECTION. DLPMIRON OF KWAOE DIVOSAL EYEL6/E. 3.p DNRIPONED OUTUNFE AND LOCATION OF ALL MITNO ANO PROPO613D STRICTIHEE. G.LOCATION OF WENS WITH N ILAWa OF OFR HUNDRED FIFTY FT,ON e LLDNO COVERED AREAS SUCH AS PATIOS,DAVEWAY/,AND WAIXS. THE PRDIERTV OR AD.FOSRFO FROPERTY' Aj : .. _ _ :... .. ........ ... .. . .... .. i._ .... 41, .:: . :.... k. ' ..FAYMEN7 :. .. ....... . ........ . .. pmt` .. ..� 'TaiG . ►iil� F SEP 241998.. ...... ...... � ..i+ ... .. - .... - I.J., - _FUESLIQ NFAI T ti"` ,�f ENViT'ONMENTA • FOR CEPAPTMMT EER ONLY APPUCAMN ACCEPTED 0Y DATE N TANK,PTT OR SOAP NR'fCTIOU BY DATE / I FINAL SF4'ECT10N BY �� / / ADOTFIONAL COMME 1: ACCOUNrlA1O ONLY: AIW fACF PE cOOE FEE INFO A-MQVNT RM ITIP A- RBC ST DATE M/FREAST RINERI INV0ICI E ..2 �� / �i SA r,110 1� Pub.Health Sart-ErMro,174 f3/K A�