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APPLICATION FOR LIQUID WASTE PERMIT <br /> SANJOAOUIN COUNTY PUBLIC HEALTH 1ERYMES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O,BOX 989,904 EAST WEBER AVENUE/STOCKTOR CA MOI-390 <br /> 12011 1114420 <br /> NOIEREFVAGAILE PERMIT EXP-110 1 YMN 1`001 Q1TE Itf ID <br /> K4""In TrWhob► <br /> "FIXATION 14 PUSSY MADE To THE TAN JOAOUIN COUNTY FOR A PFRMFr TO CON/TIRWT AWDAM INSTALL THE WORK DFSCIIBEO. THS APPUrATION ISMADE N COUNJAN[E VATM BAN <br /> JOAOUN COUNTY DNELOFMENT TTTLl`.�CHAPTER 9-1110.3 AND THEN STANDARDS OF 644 JOACI N COUNTY FVILJC HEALTH SERVICE/.ENVIRO,N,AA TAL HEALTH 01%AWJN. <br /> JOS ADDRSSSA7R APAP__ —4�O L� ` /' W C('-�J`Iia A O / �CITY� �c i 1- � —LOT `e <br /> OVM"'S NAIAEC O lj[G. f n 4l�`�J�NEES_ �('7 t l C 'e i" Mq'1E i AI(5, <br /> coNrRAnnR__^__�/�,'LI 1.=1,'f ADDRESS W n ig,ox uCE C c _FHDHE <br /> SINE CONTRACTOR A00I9EE UCP "we <br /> TV"OF sfirm WORN(: NEW INSTALLATION❑ REPANIIAOOItION E3' DrTRYCRON❑ <br /> MO SNTK SYttM PLRMArTIED K PUSJC/EWER IS AVALAKE HSTHN JOO FEET of oUN DO4.I PERe TESTA!1 I How MANY <br /> ""����""�� yy7-- APMsMII1 <br /> NSTALLLATION WRL SIMM; REMDOICE O OMR❑ <br /> RLMML OF LOOM WTS: NRMM1 W/ "'SHS/"a,MAPLOTO: <br /> CK-JY CTER Of E00. DEP <br /> TO A DEPTH Of 7 Ff1T: Y ASMPTTULI►ECHARACTER: WATER TAKE lX►RI <br /> SEPTIC TANKIOILA"TRAP ❑TYPEMPO� CAPACrTY NO.COVPARTIAlms <br /> RIM TREATMENT PLANT❑ OMTANCS TO RWIEFT: WELL FOUNDATION PRDFERTY UNI <br /> LMT NYATWH❑ an TV"OF/t1N BAND OIL SEPARATOR NNACLOKD MTpO -7 <br /> VIALTMNNa LJPIE "NO.S LENGTH of UNFB��._ a'n I FAST AHC&To NEAREST:VVIL ?lr ►JIM/ATION nfl FIbPeRY LINE ^� IV <br /> RTW SSD 13WTDTH LENSTHDE►TH DISTANCE TO NEMER:WELL__FOV.TID. PROPERTY LDR {l <br /> WOUNDED WIDTH LENOTH DEPTH DMTANCE TO NEARER:NQL FOUNDATION PfbFERIY LJEE_ <br /> gEPASf IAS EO OIPTN SQS �MD/&ER DISTANCE TO ILAIE'S'r:N41 Q J,FOUNDATION=PROPERTY LNS�! <br /> SUMS ❑WDt14 LBOWTN DOTH DISTANCE TO NEAREST.WELL= FOUNDATION PROPERTY Lim <br /> DISPOSAL PONDS ❑VA M LDOOTH O-Frw DISTANCE TO NEAEST:WELL__FOUNDATION PRIOFMY LINE <br /> 1 KNEW CERTLFY THAT I HAVE MEPARED TME APPLICATION AND THAT TAM MORAL WALL BE DONE N ACCORDANCE 1,WrH MAN JOAOUM COUNTY ORDOWMCES AND RATE.LAWS,AND RAND <br /> AND IEMRATIONS OF THE MAR JOAOUIN COUNTY./DMS OVRIEROPUC&NSIO A006-0I ONATURE CDfrEEM M P)LLOVAND:'I CERTWYTHAT N THE/BEORNIANCE OF THE WORK FORLNaw <br /> THIS PERMIT IS ISSUED.I SHALL NOT DAFLOY ANY POISON N SUCH A MANNER AM TO KCONAE SUEJECT TO WORKMAN'S COMFiNSATON LAWS OF CAUPOISM.' Cow".4cTORY NMMD OR <br /> fVECOMRACTNO S INAtURE CERTIFIES THE POLLOWMO1•1 cf%Twy MAT N THE PSIMONSAANCE OF TM VVO!K FOR WHICH MS FMMtr a mom,1 SHALL am-Loy PUMOIIM SUEJECT TO <br /> WORKMAN'/COMPENSATION LAWS Of CAlPO1SSA.• THE APPIJOANT Wier CA:J.24 HOURS N ADVANOS p"AU I�.YM EMKU <br /> ► TIONS. COMrrF DRAYIAEIO BLOW. O <br /> BONED x IAl—�—_ ,t�il� TITLE: Gy+l <br /> MOT RMI IORAW TO SCALER SC.ILE <br /> 1.NAMES OF STREETS OHI NOAOS WARM TO OR BOVND"THE FNDPPRrY. A. LOCATION OF HOUK SEWAGE ONFOSAL IT"fM OII PROPOOM <br /> S.OVILINE OF THE PIgPERTY.VAT"DMABISONS ANO NORTH OUECTIDH. EXPAIJSON OF SEWAGE DISPOSAL SYSTEMS. <br /> 7. OYBNNO AND OUTLINES AND LOCATION OF ALL EJOSTINS AND PROPOSED STRUCTUEM. I. LOCATION OF WELLS WITHIN RAMA N OF ONE NWDAID PARTY FT.DIN <br /> NCUJDHIS COMED AREAS SLICH AS RATIOS,DIIVE.WAYS,AND WALKS. THE PROPERTY OR AOJOINEAS PROPOITY. <br /> • r <br /> r <br /> O m <br /> ° . <br /> . . ...:.... <br /> HE <br /> : . <br /> .... .. . <br /> •lr�+•�nNki Y, <br /> ..........:... <br /> FOR DEPARTMENT LME ONLY ^j 1 <br /> ARLICATION ACCTDTTO BY <br /> TAM,FIT OR MLIIAF NS'fCTNON SY DATE / I PERI EMKTION BY DATI�� / !!6 <br /> ADDITIONAL COPA MENTS: <br /> ACCOIMRNO Y: ANDS fAC/ <br /> K'COOS AMO VNT pApArTcD NEC JCAMH AE:MVm NY DATI N I MIMST NLRMMI /MIMICS P <br /> ?I oa7g3 � <br /> A 00 9 <br /> 5cl <br />