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APPLICATION FOR LIQUID VIASTH PERMIT ��� <br /> BAN•JOAQUIN COUNTY PUBLIC HEALTH 6ERVICES + i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WOO AVENUE,STOCKMK CA 95204388 <br /> ' f2UlI 486.342Q <br /> NOIPRFVIDAIL RM P f A BSB obs—16 V U R <br /> jMklM iN TrIIiRAEul <br /> APPLICATION 16 fiFIESV MADE TO THE MAN JGAOUDN COuNTV FOA A PERMAIT TO CONSTRUCT ANIOIOR INSTALL THE WORK UE9CNlm.THIS APPLICATION N NAM RF COMPUAHC[WTH SAN <br /> JOAquW CDIMTY DEVEIAPM HAP�fFE/l79 9.111 ANO T DAIOB OF MAN J13AMM COUNTY PUKE HEALTH <br /> JOS ADDREMEfOR APNIA /fie V� iHELTHM RIMS.ENVRONMEIRALHE <br /> AL <br /> T <br /> H Oemll. <br /> -et FCR `f ktcht— tI75?,6 tG <br /> I OWNEFVS HAW- )�,� ,i /y)�y�� AODRF6M /� } ♦. PHONE --TT <br /> CONTACTOR__Rc..,FL4& T�-Q.�'Y-' AODM.:R 0,2.s.`- L13 5 L_1 I/1�+1n�n,– . PHONE <br /> SIM CONTRACTOR_ •��ADDREMSI Z.I � 6I 4J40,A.�($1_ 4T LICE �p1pNF�� <br /> TYR OF OWTIC WON[: NEW INSTALLA FSTAFNAmipom O caTRUOTION 0 <br /> OTO ffRIC SYrMEM PENMTTEO W PUBLIC BEWER N AVAMABLE WTHIE ZOOFW OFQUIUWNG.I P91C 7A►D!r!HOW MANY <br /> APPFaAR1HR r <br /> DLATMLLAT1ON WNL F9NE7 REIIOENClfCDULEERcML E3 OTNvn Q <br /> NULLMLR of uvma Lwrrit; / WOAM OP OOM1r �I� NlSlrsl OF 6NPLOTLO: PAYMENT <br /> �CH ER SOIL TO A DEPTH OF.?FEET. G PFUMW SOIL CH19M.CTFA:� V Hyl rY/ATEI9 FASB!OEPPH �Cd11�1_1�� <br /> IUORFASF TRAP ❑TYPfSATO .7' •![fLr{ cAPAcm 'TT� dfY��/ PIG.eoAEPNi1MFNFs �y <br /> MCO rIQIrNHR FLANr❑ OttrArAEE TO Nr/ACST: 1Ll rovNOATtOW giOFEIRY LNN r p /n^^ <br /> UFl SI�ON❑ CS6 TYPEOF PLNW SAND OIL SEPAMTOR(ENCLOSED SYSIET.0 <br /> LUICNND ERNE HO.f LENGTH OP Low$Zs'"ZID� t I t��L OWTMICF 70 NEAREST'.WELLPO9N'IDAT10N 5�4 <br /> FRrm Sm ❑WMOTN V.ENOTM_GERM ONTANCE TO NEAREST:PM4 • TIOM <br /> FMINDA -I�•tr�Yi <br /> _...14k1�19rPe4Ae.fYlnelnA^�_ <br /> MOUNDED 93 wmTH LENGTTV DEPTHDISTANCE TO NEAVESTI WELL FOUMDATEM T PHOPENrrung r <br /> SEWAGE RTS j>vrw l!ZV am _NLIMSER� DwANCE TO NEArev.WEU wUNDATIWL /�4RERrr LIAR_/OD <br /> aUw" 13WmTH IEAIDTN W7# DISTANCE TONEAHFSrIVLLL FOUNIATiON MOVER,VLAE <br /> L9NPOSAL FONDS CI VADTM 9EMVS DERH DMTANCE TO NEAREST:WELL•, POt"WATWH FwoPERTY UN <br /> 1 HERTSY CERTIFY THAT 1 HAVE PFEPAREO TNS APPLICATWH AND THAT THE WORK WILL ME DONE NR ACCOTEANCE WITH SAN JOA WIN COUNTY ORDINANCES AND(TATE LAM AND IMR[S <br /> AND AEOULATIONG OFTHE SAN JOAOUM COUNTY.HOME OWNER ON LICENSED AOENT'S SIONATUIE CERTEIEST9E FOLLOWSN:'ICBRIFYTHAT IMTHE PERFORMANCE OF THEWWORK FCRWWMN <br /> TKO PEFFNLT IS ISMUEaNY r I SHALL NOT EMPLOY APERSON W SUCH A MANNER AS TO IECOIIE #AWI <br /> FUOJECT TO WOAN7 COMPENSATION LAWS OPCALWORAA.'CONFILWYOR'9IIIRSO CH! <br /> SUSCOMMCTIHO SIONATM CERTOM THE wLLOWSNG:-1 CERTlDf.*HAT W"K PEREOISAANCE OF THE WORK FOR WELCH INS PVINfT IS IBVJt%I WALL V*WV PERIrDFr6 SUBJECT TO <br /> WOTKNAM'I TION LAWS OF CALMANU.' Ti FF�,Am MUST CALL 24 NOW IN JDVARCE PoR ALL ILmLmm I wwnoiw CMLIFIFTE wAWON BELOW. <br /> MIOTItp>< LZ <br /> 1ffLE: DATE:- I Z�0 <br /> —" PLOT TIAN BMW TO SCALEI SCALE •VS <br /> I-NAMES OF STFEETB OR ROADS NE sr YO OR SOUNDING THE PROPERTY, S.LOCATION OF HOUSE SEWAOE ptePDDAL,sYSTUI OR NIOw/ED <br /> E.OUFUNE OF THE PROPERTY,WITH OWENSNONN AND NORTH DIRECTION. EXPANSION OF SLWAOE ONPONIL SVSTEUS. <br /> T.D"NOONEO OUMUMS,AND LOCATION of ALL ERIOTINO ANO PROPOS D STRUCTUADg. '11.LOCATION OF WELLS WITHIN RAOAM OF 04 NI91dEp FIFTY R.ON <br /> HCLUDING COVERED MEAS SUCH AS PATIOI.ONVEWAYS,ANO WALXI. THE PFO ElW OR ADJONIMO PROPERTY. <br /> .,. .. .... .. <br /> I� <br /> .: <br /> f. 4 <br /> .: . a '.. <br /> y�- <br /> : . .. <br /> .......� .. .�.......:.... ........ ...p...........n................. .,.. ......_'...................3.... .... <br /> v. �................... <br />� O DW 7RHDR WEOHLY <br />! I APPLICATIONAL`CEPTE9IY oAT'E: ASR <br /> i <br /> TAW,R'1T OR Si1Mp RLSPFc Y OATE� FM1AL IM8 DATE a� . 7 <br /> i <br /> ADGRORFAL MMEWS! d 7 <br /> -Y. <br /> ACCOUNTING ONLY: AID# PMS --~ <br /> OF CODE FEL GRFO AMOUNT OBATTIM CNICKfMASH INV SY OSE M I F7•SAIT NLSIHT RNYOISEf <br /> Yl L TV'— 19Dl <br /> I - <br />