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APPLICATIC 'LIQUID WASTE PERMIT J SAN'JOAOUIN C*SeY PUBLIC HEALTH SERVICES No ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388, 446 N.SAN JOAQUIN ST,STOCKTON,CA 962010388 (209)4683420 NON REFUNDABLE PERMIT EXPIRES L YEAR FRDM DATE ISSUED / (ClRPIFM IS Trl kit.) APRICATIDH IS HEREBY MADE TO THE SAN JOAWIN COUNTY FOR A PFAMR TO CONSTRICT AMIOR IN'.THE WORM DESCRIBED. THIS APP ICATNIH 18 M/AE W COMFIINICE WITH AhDVIN COUNTY pEVDOPMEHT TR1F-CHAm A.1110.3 ANOTHE STANDARDS OF SAN JOAOUIN CODHTYMAX HEALTH SPRVICES.¢N/yroxMENTAL HEALTH DVISION. JOB.'"ANS0.AANA_ — jO y.fGy_k -,Pf aO r/s /� LOTB�y Onc::T OWNER NAME H ADDRESS /o ld "7 al() G–a r5 rf RI1oNE 4'�.C' -/E/S LroHrlucroR At•,/ :2. Jksail aAsnt. WRESS al AJ. //n..:�n.n �A ucs PHONE Y71 -/O Eel BUB CONTRACTOR ADORES{ 1,Ky PANE TYPE OR SEPTIC WBAR, MEW INSTALLATION❑ REPANVADDTpN ❑ MAUR CTIOM❑ IND SEPTC SYSTEM PERMITTED N NBIK SEWER IS AVAILABLE WTTXIN 2.FEET OF BURDINO.I FRC TESTA)I 1 HOW MARY_ AASSARN�P JN 1 INSTALLATOM WILL{BNL KMDENCF❑ COMMERCIAL O OTHER❑ NUNREA OF U SNO ANN&: RUSSIA OG BEDROOM{: NURA EA OF BA0.0YF9: CHARACTER OF SOIL TO A.DTH OF 3 FEET: NT/SUMP BOIL CHARACTER: WATER TABLE DEPTH [DTIC TANKroREABE 1HN ❑TYPEMFO AFACT' NO.COMPARTMENTS RU TREATMENT RANT❑ DBTAMCE TO NEAREAT: WELL FOUNDATION gpKgrY UNf UFT STATION❑ ARE TYPE OF WARP BAND OIL SEPARATOR IENCLOSEO EYSTEMI UACMMO UNE 0 W.&1 THOFUKE DBTANCETONFAKBT:WELL FOUNDATNIN FROP UHE PETER&ED ❑W10TH Ul*UN DEPTH DSTANCE TO NEAREST:WELL FOUNDATION RIOPER, HE �1 Y MOUNDED .WIDTH LENGTH D H DISTANCE TO NEAREST:WELLFOUNDATION RpKNTY UNE FEEPAOE PTS ❑DEPTH SME NUMBER_DISTANCE TO NEAREST:WELL POUNDATNIN PROPERTY UNE ^\I SVMK ❑W1DTN LESSI DEPTI OSTANCETONEAREST:WEULPOUNOATpN PROMPT,UK \G\ dBPoBAL PoNDB ❑WIDER LEI CEFTH DBTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE I HEREBY CERTIFY THAT HAVE FIRER THIS AREICATWN AND THAT THE WDK WILL BE DONE NI ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AHD STATE UWe.AND WLES " ANOREGUTATIONSOFTH BAN.p CO .PENEOWNERO.UCENSED 'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFYTNAT IN THE PERFOPAANCE OF THE WOW FORWHICH THIS PERMR IS ISSUES,I SHALT. T Y PARSON IN SUCH A M TO BECOME BUBJECTTO MIO MAH'e COMPENBAT.N IAWB OF CA ..IA: CONTRACT.W B HINNO OR \ 1 SUBCONTRACTING SIGNATURE 8 .YANG:•I CEMNY THE REPEORMANCE OF THE W911E FOR WNICH THIS PERMIT 19 168 I SHALL EMPLOY PERSONS SUI ECT TO VAPtMAN'B COMRHSpTN)N FC IA• CpLLbMONIM IN ADVANCE FOR ALL LREBUNE`D/IMAMMAS. COMPETE HAWING/SEIAW. J SIGNED TILE: / `G,/jT.C/4 N DATE:_) ROT RAN IURAW TO SCALE)SCREE I-NAMES OF STREETS OR MAD{NE V TO OR BOUNDING THE PROPERTY. 4.LOCATION OF MUM EEWAGE DSW SAL SYSTEM OR PROPOSES2.OUTUNE OF THE RIOKRTY,WITH DMENSIONS AND NORTH DIRECTgN, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED SLOCATION OF WELLS WITHIN gAgUS OF ONE HUNDRED FIFTY FT.ON ITRUCTURES, S. LL NCLUDNG COVERED AREAS SUCH AS PATgB,DRSS WAYS.AND WARS. THE PROPERTY OR ADJOINING PROPERTY. ��9 PARCEL ON, 10 Acro NOAw IRW1OM ?• N G �f 3 EA PARCEL TWO �. 10 ADrK p� O PARCEL THREE PARCEL FOUR ILL . 10 9cAereE . PAYF�i �T r„,1 i P. .E r E': ,a Fl.1ir :. IAKwwr qr srnm y l Htiv 2 1114 TATE HIGNEAT EDurE $ MD r 7- 6fiLV J�JA 4',NL-w IfY ;DU3liL.Y'EALT'�Sl I:6:5 tf:LI,R=',`pti Fr TP' ( fll f1'V161n?1'". _ l... 0 � � /� GOP DEPMTMFHT USE ONLY SPECKATION WM PTED BY V , DATE: ZL pgEA: TANG AT OR SUMP NISPECTIOH BY DATE / / FINAL INSPECTION BY DATE_//,L�a AOD?MNAL COMMENTS: T1` ACCOUNTING ONLY: AIDC FACS K CODE FEE INFO AML•"'- TT. MASH j RICDVED BY 1 DATE M/FBIMT M11Me91 pVOR!/ zzz 3L;L p