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APPLICATION FOR LIQUID WASTE PERMIT 4� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> R4wREFVRDAPLE PEAMIT"PIPES I YEAH FROM DATE tSSUEO <br /> (c..*wE he TT4E.E1l1 <br /> APLCATION IO NERMAY MADE 70 THE SAN JOAGLIN COUNTY FOA A PERMIt t0 CONSTRUCT AND/OR MfTALLTHE WORK DESCRSED,THIS AMUCATION ISMAO(N COMPLIANCE WITH SAN <br /> JOAGUIN COUNTY DEVROM.IENT TIT11.CHAPTER 8-1110,3 AND THE STANDARDS Of SAN JOAOUN COUNNTfY.PUBLIC HEALTH SEINE LS..151041 OMADnAL NEKTN <br /> JOE A0011E801OR A.w / &/O 1 C/��1' lL�e-, L�C-I , ,1�a Cm / ��T'L/ '] LOT eRpj/ <br /> OWNFR'S NAME_ h a C-01A �. ADORED! `••� _T <br /> c.P,AcroR cRZTo-V L` ADDESEL�I . �'h .�l S��C L., ��" 1'11fiNE 3�S3`f3 <br /> elle CONMACTGR AnOmse LICA PONE <br /> TYPE OF f PITC WOMB: MW INSTALLATION RFIMNAcwpom❑ OUTMXTION❑ <br /> IND SEPTIC SYSTEM P7MIITTED E P'JBUC SEWER p AVAAAUM WRHM 200 FEET OF RUI DINGA POLO TESTW I 1 HDW MANY <br /> IpI^/ <br /> IApOmfen f <br /> WS7ALLATNfN W1µsTRUE_ RESIDENCL❑ COMMERCIAL Pr OTHER❑ I <br /> "UNISON OF EMKO FTS: NIMSSR OF BEDPODOMS: (yam•�9O fFfEk A`L ti S �/ J O/� 1 <br /> F�-OF SO4 t0 A OEPTN Of 7 FEET` PR/RUMP Hdl CHARACTER: WATER TABLE VEPTH"RAP ❑TYFEAN _ CAPACTTY tLl�` P� NO.COWAATMENTEATMENT PUI-N-IT❑ 04TANCE TO REAAMT: WELL 2�2 � FOUNDATIONL PROPERTY UNE <br /> UFT STATION IJ SIZE TYPE If PUMP SAND OR SEPARATOR IENCLOEEO SYSTEM _ <br /> LEACUSNG UNE PC NO.RLENOTH OFUNESL7-/Qd /.'Yte 5 DISTANCE TO NEAREST:W chO FoUNrATIDNPOP[RTV Ln* <br /> PrLrm Sm ❑WIDTH LENOTM DEPTH DISTANCE TO NEAREST;WELLFDI/NDATIDN POPETTTY LINE <br /> MOUNDED ❑WIDTH LENOTH__OEPTH DISTANCE TO NEAREST;WELL ""MAMN POPDRY LINE <br /> SEEPAGE PTS ❑OETN SIZE NIINIKR DISTANCE TO NEARER:WELL .EOIINDATgN PROPERTY LINE <br /> sWPS ❑WIDTH LENGTH _DEPTH DISTANCE TO HEAACEF:WELL _FOUNDATION "WOCRTY LRE <br /> OMPOSIIt POND! ❑WINTH LENOTH .DEPTH DISTANCE TO NEAREST:WEU__fOUNDATDN PROPERTY LINE <br /> I HERESY CEIITfY TNA7 1 NAPE PIEPA NNIS APPLICATION AND TH i [WORN WiLL EE DON[N ACCORDANCE WRH SAN JOAQUIN COIINTI'oIOMAMZS AND,swe LAWS.AND RULES <br /> A/A IEOUATgN6OF THE MN AA NCOVNTY.IDME OWIERM [H AOEMYSgNATLNE C(RTIPESTM ROILOMNG:•ICEMIFV THAT NTHE F[MOISINICE OF THE WORK PORNRSCH <br /> TMS ff ISSUED,1 RIOT ROY ANY PERSON 01 SUCH Mur, AS TO BECOME O JECT TO WORKMAN'S COMPENSATION LAWS OF CNNMA.'CONTRACTOR'S HIROO OR <br /> su" SIO" C [ FOLLOWIMS:'C E OF TEE WOIR PCR VAMN TMS FEWIT IS ISSUED,1 SNAIL[S/LOY PLI�OIR SUBJECT TO <br /> AN'S T We IMA., TTHE/ T MN CALL M HODU M ADVANCE PON AL1 IRSPSCMNS.COMPLETE LSUWSR BELOW. I 9^y' <br /> PON <br /> ED ! v mLE:_ `...M/ DAT[: / V <br /> 1 <br /> PLOT PAN IDRAW TO SCALfI CNN_ Ie <br /> I.NAMES OF STREETS OR ILDADI NEATER TO OR BOUNDINO THE PFEUPERTY. 4, LOCATION OF NOOSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY. IR <br /> ITY.W TH DIMENSIONS ANORTH OECTNW. EXPANSION OF KWAOE DISPOSAL SYSTEMB. <br /> O.DIMENSIONED OUTLINES AND LOCATION OF ALL EAISTINO AND PROPOSED STRUCTURES, E.LOCATION OF WELLS WITHIN RADAR OF ONE HUNDRED FFTY FT,ON <br /> NCLUOING COVERED MEAS SOON AS PATIOS.CFEVEWAIM AND WALKS. THE PROPERTY OR ADJOINING PROFIT"- <br /> . <br /> .�... "ti ....,,. ... ..... <br /> - ................................... <br /> :.P�4'Y <br /> . :........ .. <br /> AsaT•'.� <br /> .... . ... v 1 - .._.. ........... - �KUUiN f;G ...... <br /> M 3. . . :_ El+vpoN �/ yEairE <br /> ..� .... <br /> .. .. .. ........... ... ...... ... ..... .. ........ t-ICu9aC ... '....< .. .. <br /> t <br /> FOR 017APTVANT USE ONLY <br /> APPLICATION ACCEPTED By DATES N;f A: Z i <br /> TANK,PR OR SUMP R48FICTION BV ATE I I FMUL INSPECTION BY ATE <br /> ADORI04NALCOMMEHT6• ` �•�tl <br /> ACCOIINTI'q ONLY: NDE PM1CI <br /> F--FRUITEDAAAOUPfT MERITED ■Y DATEK/Pls1ST IOALR�1 INVOICE! <br /> Pub.Health S.,-E-trD.174(3/06) <br />