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APPLICaT10N FOR LI;<Ui0 WASTE PERMIT <br /> O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES V J <br /> ENVIRONMENTAL HEALTH DMSION <br /> 304 EAST WESER AVENUE,STOCKTON,CA 95202 <br /> (209)468.3420 <br /> R0WIMURGAM PE01L E%PIBE!_1 YEAR FROM GATE 1959ED <br /> complete M FfwbsDS1 <br /> AMWAIWN WHEREBY MADE TO TME BAN JOAOUIN COUNTY FOR A PERMIT TO CD"sFRUCT ANWON INSTALL TNF%ORI DEScIOSED.THOS APPLICATION IS MADE M COM gjAW.E WNFH VAN <br /> .AAOUIN COUNTY N[VMOPPIAtf TIRCT <br /> E. RAPTER9.1110.3 AND THE STANDARDS COMM JDAONN COUNTY IRIOLM HEALTH SERVICES.ENVIRONMENTAL VIROENTAL HEALTH DM=m. <br /> JORADORESGIMAA/PNO 1-?�` ? ffi 414.'— /�.�. _ erTv LOT�SI�g�// .� <br /> OWNENITI NAME_LLLLiJl -,1ZL?I�ItAR,�r ADDRESS <br /> CONRNACf ADORES■ /{� c'��+ gcr)JrC. U+G.. tfCO s O q - wmNt <br /> OUS CONTRACTOR <br /> ADDRESS lFO <br /> �y - <br /> tTPE OF,sEpne WORK-, NEW INSTALLATION 0 IICFAIWAOt lI pw DESTRUCTION I� <br /> f UW SEPTIC SYBTEU FT1 EO IF 9 UC SEWER IB AVARAEIP WITHIN 200 FEET OF EUR.DWO.1 nTID 7EOTIrF 1 71IPW MwNT <br />' yL,y,�� M.IE1� AOPEwSER I <br /> INSTALLATION WIU SIV! NC <br /> RESIDEED CORMIAL D OTHER❑ <br />' <br /> PRIMER OF IMM UTSTO: I RLIMi91 OF SEDROOMS: '! IrUllal I OF PHFLOYEp: <br /> CHARACTER OP Oft TO A DEFT"OFpp91H FEE: ER Ti 19TMUMP ML CHARACTER: WATER TAME DEPTH_ <br /> MPTIO TARKMEASE TRAP ILFTYPUN" /076 /n4I CAPACT' NO.COWARfMWTE <br /> PKO TRMTMWT RANK❑ IRO7ANM TO ALMOST WELL FOUNDATION PROPERTY LOPE <br /> UFT WIRTRNI❑ SEE TYPE OP pump SAND���(♦OIIL OTPAMTOR ENCLOSED/YSTEM7 <br /> UACNNC UNE 8.PIO,ALENOTHOFLRIEO I- U �.LU LYSAi TIKLMITANCE TO NEAREST:wELL_(.�FOUNDATION )�. gppERTy NIEE �FM <br /> FRT6I SED 13 IM/TH L wm_ DEPTH ST <br /> DIANCE TO NEAREST.WL31 FOVPi0AT1DN <br /> UINCPROPERTY UNE <br /> MOOm I3 WIOTRf �I�+1 LANOTH;DEPTH DISTANCE TO NEAREST,WELL FaU1DwT1pNRToPER1Y UNE <br /> SHIT <br /> ADE PO �-UEPTHI�SRE�NAWM_ 1 INSTANCE TO NEAREST: C IT ` Ta11NIMTON -457ROPERTY LINE lE2�`A t , <br /> Summ ❑WORN LENSTH OEM DISTANCE TO NEN1EfTr WELL _FOUNDATION PIOrMrY UNF (_I <br /> ONPOSAL POWS OWpTH IEIOTII OEpTH DOYANCE TO Nunn. FOIRDAvRHI F'RDPE#lTY UNE <br /> 1 HERESY CERTOPYTHAT l ILAVF pREPAREO TMS APFMATION AND TMAT THE WORK WILL W CONE IN ACCORDANCE MNTN UN JDAOILN COUNTY ORDINANCES AND STATE LAWS,AND ALLIS <br /> ANDIEOYLATIONS OITM SAN JOAOWN COUNTYME.NOOWNER ORUCENOEDAOFSR'S SIGNATURE CERTIREOTHE ROLLOVAD;ICEIITIFYTHAT WTHE FERSOMANCE OF TME WORN rORVyier" <br /> TME rEMIT K HMLRO,1 SMALL NOT ERISDY ANY AETISOMTN OUCH A MANNER AS TO 0611OUE EUSJMT TO WOIECUANTI COMPENSATIDRI LAWS OFCMUVROA.•C MlTRACIVRTR NIOH6 OR <br /> SII9CD F8 OHTRACTYSRNATURE cERTW THE FOLLO WIND:T CERTIFY THAT NI THE DIE WWAANCE OF THE WOR(FOR WICII HVMS FERUPERSONS <br /> R IS ISSUED,I SHALL EPARAVY VAUNT TO <br /> WORKMAN'S MPA ENRATION LAWS OF CALDORTINL' THE A RPMANT MUST CALL LF NDUW IR ADVANCE FOR AIL.REOLATES I"rImTMNS.COUFLEIE ORAWINO RLCW. <br /> OONID% TITLE; C.!lY7Y•21SY_AbPC _ DATE: <br /> l <br /> MITI,qAM OrRAW To SCALE RECANT -n <br /> t.NAMEET <br /> ESOF STR6 OR ROADS NI <br /> AO6 H[A8770 OR OOlDSAp THE PROPERTY: 4.LOCATDN OF HOUSE SEWADE DISPOSAL SYOTUN OR"WOSED <br /> 2.OUTLINE OF THE PROPERTY.VATH DIMEN 101W AND NORTH DIRECTION. EXPANSION OF SNWAOE DISPOSAL SYSTEMS. <br />{ 3.DIMENSIONED OVTLMO AND LOCATION OF ALL EIUSTWO ANI PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS CF ONE MMDIOD Rny pr_-OH <br /> 11 IICLUDINO COVERED AREAS SUCH AS PATIOS.DRVEWAYO:AND WALJDS. THE RRDPERTY OR Ab.CMm nopEITTY. <br /> . y <br /> ,...,. <br /> p <br /> .. o <br /> A <br /> � s �y .. <br /> DArrJGkey 4 <br /> puaL1G xE1u.. <br /> . - NHIE47TALTiEV1-iM .. �. . ,� <br /> ., ..: . .. . :...Er! RO..... <br /> .. .... <br /> 1 ....: .. <br /> . .............. ...... ... ....: :.....,s ....:.. .:.,.... <br /> FOR 011PAPTMENT USE ONLY <br /> APH'UCATION ACCEPIm By Y ATE: µEA:_ '7I <br /> TAW,RT OR SUMP INSPFCTIDII BY — - DATE 1 ! FM/IL INSPECTION 8V ,.DATE 7!2 911 / <br /> ADDITIONAL COMMENT I: ©� � <br /> ACCOMM110 ONLY: A.- FACT <br /> 7i CODE FEE IIr:O AOEOIIRT R9AITTD OIIEC ASM IECaWI®EY DATE N17 p6EAT INSiP86L IM0lCE I <br /> Pub.NORM Saw.-Emlro.174(W) <br />