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APPLICATION FOR LIOUIO WASTE PERMIT <br /> r SAN'JOAUUIN COUNTY PUBLIC HEALTH SERVICES Cap <br /> p uu <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 368,446 N.SAN JOAOUIN ST., STOCKTON,CA 911201-61# <br /> (209)4683420 <br /> MON—REFUNDABLE PERMIT EXPIRE, YEA ROM DA ll�- <br /> c <br /> rry� <br /> APPLICATION'a HEREBY MAIM!TO THE BAN MAOUq COUMEV MR A PERMIT TO COCNSTRUCTRANO AIIN{B ALL THE WOW( <br /> MAOUIN COUNTY DEVELOPMENT TERLE,,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN M.'"C STA t HE NFFELTH GRAW ENVIRpNM NUFAME WITH <br /> .pB AOORESegRAPI�l/ ?ry �cnch r P m LOr BQE <br /> DIMMER'S NAME ( ILC T'I.Lc Tr�jl a A o wDREw Sf.L,I —11411{ <br /> '- ^ HONE <br /> WNTONTRC AwRE[6 16,.we LCF Iwxe �ByL <br /> AN,CONTRACTOR ✓�L���H<!� Aoor[BB A LIDF fD,1G�4 MIONFI,'lS-Ti'3, <br /> BASS <br /> TYFF OF SETC.0.: NEW INSTALLATIONp AU`AM/AOMTION ❑ ppTRMpm.O <br /> ;NO SEPTIC SYSTEM PENARTED M RIBUC SEWER IB AVARA.WITHIN 200 FEET OF BURVINO.I FNC T4TH1 I 1 NON•MNIY <br /> hP[aMA I <br /> N{TAWTgN WILL{WVF: RE610FNCEp--`OMMFPCIK❑ OTHER O <br /> EUINq OFLNNO—T{: I UU{q CF.EEROOM.: 3 NMA{61M WROYEf6: <br /> :HARACTER OF WN TO A DEPTH OF�]/fEEf 'Z4,IPT/SUMP WO ! I CHARACTER: WATEM <br /> R TAE DEPTH <br /> IETCw"MUSnM{[T ,1FTYPf/Mw I01-L LFE%cAs{-.[_ cAPACm IaY>rY NO.COMPARTMENT, :L <br /> M[O TREATMENT RANT O gBTANCF TO NEAREST: NEL MUNDAMN PpPFRTY(WF <br /> LIFT{TATION 0 G2E TYPE OF TPYMP /� SAND OIL SEPARATOR ONCLOWD SYBTFMI <br /> ..NO <br /> MNO ME u-NO,SLENOrHOFLNE. R� 4al DISTANCE TO NEAREST:WEJL�L�If wNNDATMNI lt)I pwREflEy LNE <br /> 4LTEA{ED _ 13W1pTN IFNpTH <br /> AOUN DEPEND DISTANCE TO NEAIIEBT:WELL FCMOATMN�PROPER,,ME <br /> AOUxDFD ❑WROTH LENOTN DETI CUSTANCE TO NEAREST:WELL MUNOATNN_Rtl PERRY UNE <br /> _ HERS.AT{ ❑DEPEN BOE NUMBER ORTANCE TO NFAIIEBT:WELL FCUNOATM N PMI4RTY LINE <br /> E������ <br /> 4U1APS Ta WYMHIENOTX�6_OFPfN,��gBT.WCE TO NEAREST:4Y91-jaci!_wUNOATMTN 1111 PpI4Rry LME <br /> M{wSAL MHO{ ❑MOTH L£NOTX DEPTX_gSTANCE TO NEAREST:WELL.MUWATWJ ARM,ME O <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLCATW N ANO THAT THE NroM WILL BE DONE IN ACCORpAHtE NITN B.W JOAOUIN COUNTY OgpIHANCEB ANO STATE MWS,ANO PLEB <br /> WD PERMIT OF THE SAN JOAWIN COUNTY.ROME OWNER ORLCENSEO AOEM'BMONATURF CFILTINfSTHE wLLOWWO:•ICMR THAT W THE PERFORMANCE OF THEWORFORWHICN <br /> 'HIB PERMNU IS 166 <br /> I SNALL NOT EMPLOY AHY PERSON IN SUCH A M.WNM AS TO BECOME WBJECT TO WOALMAN'B COMFENSATb.MWS OF CALIFORNIA' COMMCTOTS NIWNO OR <br /> VONFMAUpCMACTING SIGNATURE CERTWF6 THE FOLLOWWO:'I CMIFY THAT N THE PEAMRNANCE OF THE NOW,MR WHICH THIS PERMIT IB ISSUED, SHNL EMPLOY PERPoN.SUBJECT TO <br /> VOR(MAN'S COMPENMTION LAWS <br /> 1 AOIFFCCA MNNIA' THE APPLICANT MUST CALL 2F HOURS IN AOVANCE wR ALL R[RANO INSPECTION{. COMPLETE DRAW11q BELOW. /] �T <br /> ` 4GHw% .I�-016fY� TITLE: AWMI r CAM - J4 -1 Fes- 'ILII` <br /> PLOT ALAN IOMW TO SCALER SCALE l <br /> .NAMES OF STREETS OR MADS NEAREST TO On ROM..THE wOARry. •loA. LOCAMN OF"OUSE BEWARE DUM BAL{YSTEM OR FROM.0 <br /> OUTLINE OF THE PIIOPfATY,WITH ONMENMONB ANO NORTH gREMgN. MPANSION OF FEWAUF gSAHU,BY{RMS. 1 <br /> I. DIMENSIONED OUTLNES AND LOCATION OF ALL EXIRINQ AND PROMISES STRUCTURES, S. LOCATION OF WELLS WITHIN MpU6 OF ONE M.111,RN } <br /> INCWONO COVMO AREAS UUCH A6 PATIOS,DRIVEWAY.,AND WAU(B. THE PRUFFM OR ADJOINING PROPERTY. <br /> (71 <br /> AAAA. AAAA _ <br /> 9 <br /> D <br /> 0 1QI; <br /> E1` <br /> 9 <br /> to c - 9) a1 <br /> Lfa ETT <br /> y�. AAAA AAAA AAAA <br /> I l� -> <br /> M.DFPMTMFNT USE ONLY <br /> •PLICATmU ACCEFTEO By - _ / _ Zlg <br /> pwre: <br /> WN.RT OR SUMP INSPECTION BY GATE / / FINK INSPECTION <br /> >OITIONAL COMMENTS: <br /> s <br /> ACCOUNTING ONLY: A10I FAC. <br /> OOE INFO AMOUNT REMITTEDCNECNI,L AISN'� RECOVER{Y OATF OFIPOMUT...OL IXVOIC[I <br /> BOB, TK L J <br />