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APPLICATION FOR LIQUID WASTE PERMIT <br /> �+ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL <br /> 304 EAST WEBER AVENUE,HEALTH DIVISION <br /> CA 95202 <br /> L+! <br /> (209)466.3420 SEPTA V <br /> XOX REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (GmFbM In TIIFUBEI.I <br /> MAOLRI CoM MORMADETO TN CMAOWNCOUNTY FOR THE <br /> TANTOOStOF IANANDAA COANNELM HELTHMED.TNI!IIflICAipM1!YALEINSOMAIANCf YATN RANT <br /> AAWM COVNfY OEVELOIMENT TFRL LXARDI L1110.]/J10 THF RANILAML!/OF fMl MAWIMQCOUNfY M.HEALTH f�fyn/NCG.fMVYIONMEMN HEALTH dNMON. <br /> .Rol AOO1ME WnAyP'jNF�1-1 ` -L&,y • —L/No 1� cRY /e/ ,A �L' LOT EDEA <br /> ONNFl1Y N4Af IJ 2Yr CET -IA U55EL L AODIIF.. �/ E T/TfrILJ IIJ c /f FMONf C+ <br /> GONTHALT011 11..1,rc/LLEQ Am1E.. Po, 99n EX:J /TS��RpNE/l <br /> °� eW <br /> CO. AOOIIFf. LpP FLIMIE <br /> TYPE.1 MET.WOG: MOW..T... XOMMMMTIOM❑ OGTnVCl1OX❑ <br /> WOL l.IYXTfM EEGL M.FTO.SEWER 1.AMIAf1£WRHXI]OO"1 OF XVXAN0.1 PYp lYTW 1 I NOWMGY <br /> �y AMLLVEvv P <br /> m IXIR.D <br /> I..M....: B .CE ML COMMEXLI ^ T EA O <br /> MVA.OI OF UNMO IMYS:�NUN.M M.fLN00 • XVA.XIM WROYfFt: <br /> CHARACTER OF COIL TO A DEPTH OF]FEFi: UMF WIL CHAAMAE.WAVES TALE LEFT <br /> .VTIC TAXTIELAM Tw ❑TYIEMFO cAACTrr�r/Y I��Ip.cOMPAXTMNIT! <br /> s MIO TRGTANA,RANT 13 d.TANCF TO. .T: WELLFOUNDATION MIORRrY LXIE <br /> IfT.TATIONOE TYROF.P EANO OIL Ell.....—EYRFMI p <br /> LGCNMO UNF <br /> IK ..."...'U.S. 'V-Ayn pRM10E TO AYMEXf:WELL'' IOIX10ATpNIT RMIRRTYIMF eT 'al <br /> OLTP EEO OWIOTN LENOT. DEFTH�MRAMCE TO HEARST,N91 FOUNCATTI INRRTY IRF <br /> MOVXDO [3 .T. IEHOTX DEPTH_MRMICF TO HEARRI WELL MUNOATIONMpRRT,UNF <br /> s IiGAOf Ri! ❑DFFEX .RE—��IAGSf DIRANCE TO RARRI NSLL�FOVNDAYpNLRE <br /> EIMR Pr.H 21 IEHOTN ZU DEIEX O1RNlCf TO NFARJT:WfLL�FOVMOATpN�RpRRFY UXF <br /> RIFO.AL qMO. ❑VMrH IENOTH MRN MVANCE TO NMEfT:MUS MUNLATIOH�TORRY LIN <br /> 1 HERESY CERTIFY THAT I NAVf PRPMfO T.H.APPLICATION AND TLO T THE WVR MUM CONE IN ACCDW ANCE WRH.AN MAWIN COUMY CRIONANCE!AND STATE GW..AFARM <br /> RE! <br /> ANO ROUGTMN.OF THE ENI JOAQIW COUNTY.HOME OYMNI OEMMEN,METE XOIUTUR CERTIFIES THE MUOASAGI'ICERIRTHAT N THE RI+R.VVICF OF THE NORFO.... <br /> THE.RNM IS IENEO.I ENALL HOT EMPLOY ANY REASON N SUCH A MANNER A.TO BECOME WEJECT TO NORMAN'S COMRHMTH N GWE OF CALXORNA.- CONTRACTOR'S HRIND On <br /> .U.SOMMCTINL ISOMTU S CERVNE THE FOLLRR NO:-1 CERTIFY THAT IN THE RTfONAANCE OF THE YAR FOR NMH:H THIS RNME M IENRD.1 MALL EMPLOY PERSON.MWECT TO <br /> MAN'.COMN.ATONG .WR <br /> WOOFCFOILL TMAMIDMTMU.TCALLNMWNADVANCEDIA(ALLMOMIIFDIXSRCMME. CDURFF plAWlxa.fLOW. <br /> NORR <br /> SIONO M '?- "-4-- TITLE' <br /> ROT RM WRAW TO ECALEI C.A <br /> NALE.OF STMEY.On MAD.NEMEEi TO OR...THE FEEL ATV. S.LOCATION OF HOLM.EVADE DISPOSAL SYSTEM OR FNWEO <br /> OMUNF LFTN INRRTY.M'ITH D......MO NORTH DIPECTp M. GPMSq .1.EWAOE...AL m'STEM.. <br /> _ OIMENMONE.OVIUNE,AND LOCATION OF ALL IXIST11N M0 PROMISEDSTIIVCTLRES. S. LOCATION Of MU.NTININ AApVE Of ONE HUNDRED FIFTY FT.ON <br /> ' INE ANOINT,OF <br /> ILV ONO Co,TRED AREAS SOON AS PATIO.,ORVFMM <br /> VAYEY D WAS. <br /> MAOIOININO RORIITY. <br /> P' 1 T�nYt <br /> �/� b <br /> k%E-� C�C-- <br /> c <br /> 0 Kl <br /> Jn/ 1 MR DOMTMENT USE ONLY <br /> A..TIONACCEREDEY��L—am/�/ DATE: Z REA <br /> y2: <br /> .� TAR.NT C..VMP IN.RCT.N SY OR I A fNNNWEGTpN SV OAT!' <br /> 3 <br /> AOOipNN[OMMEM6 <br /> ACCO VXTNO ONLY: NOI FACJ <br /> tl FfE INTO AMOVXT ITIO IIFC AN RCXVO SY DATE M/FUSrYT XY..61 IXVOICfI <br /> R2�1 ill - <br /> Pub.HOovi Ser -Env110.174(3/D6) <br />