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a APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST VVEBER AVENUE,STOCKTON,CA 95201588 <br /> 12091 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI'1/1 ,'SD, <br /> ICSMPAIM M T,10--UI // _I <br /> APPLICATION IB NFNEBY MADE TO THE MN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMS INSTALL THE MW MACRI THIS APPLICATION NI MADE IS COMPLIANCE WITH BAH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER'0--11110.'3 AND THE ST'N DDAMS OF BAN JOAQUIN COUNTY PUBLIC HEAL"SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR AIM1P ) L L ] IJV /]W � ��i ET' )�a�C �� VN LOT HQ% <br /> OYME11'S NAME I I ".3 ADDRESS PHONE <br /> corrtMcroR i��liiC _`a?tJ+[io s.P :� Appu66 �` o cl, ^,%j✓ (y .f/ UCE 7�,S NJ 3 PHONE`S S __f I'31 <br /> SIVE CONTRACTADDRESS UCI PHONE <br /> TYSE SFBpIIO WORN: MEW MTA M.0 ROYNADd11OM GRODEACTON❑ <br /> M �L <br /> � R���IL <br /> gO SEPTIC SYSTEM MM R FORM MW ER IB AVMABIf WITHIN 300 FEET OF BUILOINO.1 MOW TEST\I I E H E f VN l <br /> IM ISULA PI WRL BSFORG RESIDENCE❑ COMMERCIK O OTHER 0 <br /> ..O11MNO VNITE:_NVMi91 MSEORSOMi: NVM691.1 SMNOYEEA: <br /> CHARACTER Of SOIL TO A DEPIN OF S FEET: CL MU.UMP SIGN CHARACTER: WATER TABLE DEPTH <br /> SEEM TANNMFAFE TRAP ❑TYPEIMFD CMACTN NG.CGIMPARTMENTBAIH i,1:fU'.:u <br /> ill <br /> PRO CO TMENT PANT O DISTANCE TO NEMMWE <br /> T: LL Mf FOUNDATION MQ ,F,_ PUbLlGNF <br /> 'I"� F If$ <br /> ME MIT STAMM❑ BRE TYPE OF NMP SAND OIL SEPARATOR IENCIOBEO SWBTEMI <br /> IFACMNO UM6 0 ..\IEHOTM OF LdkY / _L/V INSTANCE TO NMPESIT:YhLL ATOM PMIERTY IJHE <br /> PLT.BFO ❑`M1 LENGTH DEPTH, DISTANCE TO NEAREST:WELL FOUNDATION_ROPERIV LINE <br /> M.M.O. ❑WOTN LISHEI DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SLVAOE PTS ❑DEAN SEEi NUMBER''S� '' DISTANCE TO MEANEST:WELL � FOUNDATIO <br /> N / MQVsRQY LINE <br /> i11MN OWIOTH 3E' IEHOTIJ� DEI'rH�DISTANCE TO NEAPST:N£LL/U� FWNDATONi�PROPEROW UNE <br /> diWSAL FORDS 11VJO1N LENOIN IN DISTANCE TO NEAREST:Viii FOUNDATION PMPERTYUNF <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW(MUL BE CONE IN ACCORDANCE ANN BAN JOAQUIN COUNTY ORDINANCES ANO STATE IAWB,ANO RVIEB <br /> AND REOVIATONB OF THE SAN JOAQUIN COUNTV.NOME OWNER OR UCIUMM AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I COMPSYTNAT M THE PERFORMANCE OF INEWOIEL FUM MICH <br /> THIS PERMIT IB ISSUM.1 SHALL NOT EMPLOY ANY MASON N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> BVSLOMMCTMO MOHATUM CERTIPEB THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE Of THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO <br /> VJOW.MAN'S COMPENSATION UW/B OF CALIFORNIA- THE AFPL MT MUST CALL N HOURS IN ADVANCE FOR ALL REQUIRES INSKCMNI. COMPLETE DAMAGED BELOW. <br /> ORNUO4/.(! ///LL.�" TITLE: DATE: <br /> ROT RAM OMW TO SCALD SCALE <br /> 1.NAMES Of STREETS OR MADS NEAREST TO OR SOUNDING THE PROPERTN', 1e4. LOCATION OF HOUSE AMASS DISPOSAL SYSTEM OR MOP)SEO <br /> 3. OUTLINE OF THE PMPRIV,WTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BfWAOE DISPOSAL SYSTEMS. <br /> DIMENSIONED OUTUNES AND LOCATION OF ALL E%RTNO AND PROPOSED STRUCTURE., S.LOCATION OF NT.LL8 MUDY MONS OF ONE HUNDRED FIFTY FI.ON <br /> INCLUDING COVERED AREAS SUCH AB PATIOS OWOMAYB.AND WALXR THE PROMO RY'OR ADJOINING FWP RTY. <br /> i <br /> r V <br /> D. L " ;- r lI <br /> I� <br /> C1 <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> AMICATIONACCENE BY DATE: ARFApp��P��_ 1 <br /> TAW.PT OR SUMP INSPECTION / GATE! Ia�� fINAI IRB C11ONf DAZE /P'] <br /> ✓ <br /> ADORIONAL COMMENTS: T ' <br /> ACCOVNTNOONLY: -TORE fAC1 <br /> PE COOF FEf INFO AMOVNTIMMITIED CMCNI ASH RECDVEOIY OAi6 M/PPMIT NUMBER <br /> �2 <br />