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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 JOAUUM ST.,STOCMTON,CA 95201-03118 <br /> (209)468-3420 <br /> NOWALFUNOABLE PERMIT EXPIRE?T YEAR FROM O Tf li3UE0 <br /> Mwpim In Tr4r+W <br /> APPLICATION I6 14EMY MADE TO THE SAN JOAOWN COUNTY FOR A PERMIT TO CONSTRUCT ANWA WBTAU THE WORK DESCWO.THIS AFPJCATfON 16 MADE W CCW'UANCF WRH SAN <br /> KOACERR CDLKTY DEVELOPMENT T77U,CHAPTER 51-1110,3 AND THE STANDARDS OF SA JO ACUIN COUNTY PU8UC HEALTH SERVICES,ENST"M DIVISION. <br /> JOB AOORESSiOR APNP 1 11 W L/^.`4-�'W}OL/Yf CRY '�i/�/. Lur BRE <br /> OWN£R'B NAME Lai-fYF'Yf L—�� AODRE45 PF(ONF <br /> COIYTAACTOR ��NAS A AOCREBR LCII_�.,�/ o_WIDF ,3 <br /> SUBCONTRACTORADOREE PHONE <br /> TYPE OF Rome WOR1ry NSW WITALLAHON Q RFPAWADdDON wsT1KICTRON CI <br /> INC SEFf1C SYSTEM PERMITTED If PUBLIC SEWER 15 AVAILABLE WrTKN 200 FEET OF BUNDINOJ PRC TSsTw I 1 NOW MANY <br /> bPIaRRcR A,_ <br /> INSTALLATM WILL SYNE: RESIDENCEIt COMMERCIAL❑ OTHER Cl <br /> NUMBER OF WINO UNRs:��NUMISM OF YWRGO C RIFMaER OF wmR YESs'. <br /> CHARACTER Of SOL TO A DEPTH OFF 3 FEET: FTTISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SIQTIC 7AkX'GPM 6E TRAP U TYPFIMFO CAPAUTY NO.COAWARTWENrS <br /> PKO TREATMENT PLANT C3 DISTANCE TO WAMT: WELL FOUNDATION F ROPEATY U!E f V <br /> UFT ITATION Cl�1B/RE TYPE OF PUMP_SAND OIL SEPARATOR[ENCLOSED SYSTEMA I f <br /> LEACHWA ULANE NO.♦LENGTH OP LINES_ O �NGI ANCE TO NEAREST:WFLL�Q_FOUNDATIONIPRDFFTY NLINE A <br /> RLTIA SED [3 WIDTH <br /> LENGTH OFFTN DISTANCE TO NFFPEST:WELL FOUNOATIOro PROPERTY UNE y) <br /> AIOVfIDlD 4A DTH LENGTH_mm" DfANC <br /> STE TO NEAREST:WELL FO'UNDATON PROPERTY LINE \S <br /> —m PTs X--PTH 812E�_r„NUMSER7 DISTANCE TO NEAREST:WELL�fOUNDATION-6-'!L PROPERTY LINE_ --1 <br /> "*Aft ❑WROTH UWgTH DEPTH DISTANCE TO NEAREST:WELL.FOUNDATION PROPERTY UNE /jam <br /> DISPOSAL POIIDS CL WICTRI LENOT i_DEPTH DISTANCE TO NEAEST:WEU-__FOUNDATION PROPERTY UAE <br /> l HFIRESY CERTIFY THAT 1 RAYSPRE9AI�4 REBS APIL1CATfOI Mb THAT TM WOW WILL SE DONE RI ACCORDANCE WfTK SAN JOAOUIN COUNTY ORDINANCES ANO STATE LAWS,AND RILES <br /> AND REGULATIONS OF T...JOAOLRN COUNN,NOME O EA ORUCENKD AG£NTV SIONATURECERTIFIES THE FOLIOVANO:YCERSIFT•THATRN THE P9W*RMA/CE OF THE% IWFORWFBCH <br /> THIS PEMTT Is <br /> ISSUED, <br /> SHALL NOT EMPLOY ANY PERSON W SUCH A MANNER AS TO BECOME SUSACT TO WORKMAN 8 COMPIEMSATION LAV"OF OALIPCRNIA:CONTRACT'OR'S NIWNO OR C� <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•)CFRTWYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEf"T"IBBUE L 1 SHALL EAR'LOY PERSONS SUBJECT TO ^� <br /> WORKMAN'S COMPENSATION LAWS OF CAUFO/y <br /> ADVANCE OR ALI.MOMEO TgMCOMLETE ""G SELOW <br /> EW µ Eu8 IN <br /> SIGNEDn . <br /> /Ii1/ GATE: <br /> ROT PIAN TORAW TO SGL.,SCALE _ -W <br /> 1.NAME$OF STREETS OR ROADS NEAREST TO OR SOUNDM THE PROPERTY. 6.LceATION OF HOUSE BEWARE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OIFTLNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. ExPANS MN OF SEWAGE OM OeAL SYSTEM& <br /> O.DIMEWWORED OUTUNES AND LOCATION OF ALL E%ISTWO AND PROPOSED STRICTURES. 6.LOCATION OF WELLS WITHINRMW6 OF ONE NUNIWED FIFTY FT.ON <br /> WCLUOIND CCVEPED AREAS SUCH AS PATKM OWVEWAYS.ANO WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> .. .. .. - <br /> aUSI <br /> f� <br /> ' IR{E'Y4r R 1996 <br /> S <br /> 7 <br /> tYtI4C7il AA,.t A._rH �a i.�i. <br /> FMR O®AII.IIS[ONLY �Q\ <br /> APPLICATION ACCEPTED I'f UATFI A'�r•4�--G— <br /> TANK.PTT OR SUMP INEFECTION SY DATE I f FINAL INSPECTION IEv � DATE/l P�; !S <br /> ADCTIONAL COMMENTS' <br /> ACCO UNTIAG ONLY: AIDE FICA <br /> Ps CODE FE INFO IUAOtAIT ROAITT'[D CHEC Asx AECOVED AY PATE W I FERMI WAIR t INVOIOE/F <br /> r <br /> S t,,ao V 3 <br />