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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 NOIFREfUNDABLE PERMIT EXPIIRRES I YEA ?AOM DATE ISSUED EXPIRED ICBIBPI.LB 6 TE¢Gsta) APPUC ATM IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOM DESCRIBED.THIS APPLICATION IS MADE IN COMFUANCE WITH BAN JOAOMJ COUNTY VPALGMIW TITLE.CHAPTER B-I i L .3 AND TNF STANDARDS OF SAN JOAOUN COUNTY PUBLIC HEALTH SERRNGEe,FWAMO'MAENTAL HEALTH OMSION, JOB AOOMSOMM APP/ ! C�' / /� CITY ✓/y/OL-' LOT SIZE / ONE/ER'S NAME ABOR[SA L�/ C1/ E �I a'r PHONE /y 9 COMPACTOR ®C&A —ADDRESS En PHONE SUB CONTRACTOR AUDESS UC' PHONE TYPE OP fFPf1t W011K: HEW IMSTALLARION❑ Rw^wvAmtIOM❑ DEDTRUD IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WTTHtH 700 FEET OF BUSDINO.] - PMC 7TLLTb1 l I-W MANY ANNPBESSFn I I NSTALLATIM WITL BEIM: RESIDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF WINO UMTS: NUMBER OF BmIIOOMS NUMBER OF EMPLOYED: CHARACTER OF COO TO A DEPTH Of 3 FEET: PITI6UNAP BOB CHARACTER: WATER TABLE DEPTH BBM TAIIRIOISA/E TRAP ❑TYPFJMFO CAPACITY NO.COMPARY"FW S PNB 71MATMMT PUNT❑ DISTANCE To ICEAREAT: WELL FOUNDATION PROPERTY LINE LFT STATION❑ RE TYPE OF PMP BAND OR SEPARATOR(ENCLOSED BYS7FM1 LEACMNO LINE ❑ NO.A LENGTH OF LNT6 DISTANCE TO NEAREST'WELL FOUNDATION PROPERTY LINE REL7ER BED ❑WIUTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LME MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE aFDAOS PTB ❑DEPTH BRE MUSAIER DISTANCE TO NEATEST:WM FOUNDATION PROPERTY UNE BUMPS ❑WIDTH LENGTH DETTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL POND/ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAEST:WEU FOUNOATION PROPERTY LINE 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND MULES AND REGULATIONS OF THE SAN JU OAON COUNITY.NOME OWNER OR LM INSM AOEM'e SIOMATTBE CERTIFIES TME FOLLOVAM:'I CEPTtFY THAT NINE PERFORMANCE OF THE WORK FOR WINCH THIS PER MET to MSUFO,I SMALL NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO BSCOME SURACT TO WDMUAM6 COMPENSATION LAWS OF CAL"RMIA.• CONTRACTOR'S MNBO OR SUBCONTRACTING SgNATUIE CERTMAS THE FOLLOWING:I CERTIFY THAT N THE PERFORMANCE OF THE WOW POR WHICH TMS PERMIT IS ISSUED.1 SMALL EMPLOY PERSONS SUBIECT TO WDIKMARE'S COAEENDA N LAWS OF CALIFORNIA' THE ANREJC MUST CALL K HOURS IM ADVANCE FOR ALLLRSOUNED I�NSPEECCTIONS. COMPETE 011AWN0 BEIDW. SgPEO% TETLE: '� L—`✓/ DATE PLOT ELAN MW TO BCA.D BCAU 1. NAMES Of BTIEETS OR ROADS NEAREST TO Dt BOUNGIMO THE PROPERTY. 4.LOCATION OF HOUSE SFWAOf DISPOSAL SYSTEM OR PROPOSED T.OVTLIHE OF THE PROPERTY,WITHDIMFlIB10Nt AND NORTH DIRECTION. F%►AMfM OF BFWAOT DISIOSAL SYSTEMS. 9. DMfNBONED OUTTNFS AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. S.LOCATION OF WELD WPTNN MOLLIS OF ONE HUNDRED FIFTY FT.ON tW,M O CO VEIED AREAS NKN M PATIOS.DRIVEWAYS,A/O WARTS. THE PROPERTY OR ADJONNO PROPERTY. T op ..... i. �t v 1 _ . . :. z ...:... "loci . .. .... :a ..m :..... .. ... SAk 1pAQUIPECQ:VI`'T3. . Yl3BId�1TEAtT`Ir1EBMi 7F5 >... .;... _....... .. . .:..... . . ....... . . ........... i EP.tSRR(7[II/AEkET'?l l'f-ttLT#4 pN!IBMC!�•. 11T UAI Lj14i v v`�i'Tf VT �F. A�I Y.MONLY V APPLICATION ACCEPTED By VVV"'��v"`�� DATE: AREA:�� TANK,PIT Olt SUMP NSPCTIOH BY DATE I I FINAL INSPECTION BY DATE ! I ADDITIONAL COMMENTS: ACCOURRMO ONLY: AUDI PAC' PE CODE mw WOTNT RBAITED 11Et (CASH IECeVFD SY DATE M I P9016T HARM INVOKE P S � ' Pub.H*am sem-Ennvir(oo..174(3!96) 468- /'• �� n p •H--n Y 2�-{r— L-}-X {a.�7 v'1 �n��