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'0/05/2004 15:25 4640138 ENVIRONMENTAL HEALTH PAGE 04 <br /> APPLICP FOR LIQUID WASTE PERMIT <br /> SAN JOAOUIN`raUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 386,304 EAST WEBER AVENUE,STOCKT'ON.CA SL5201-388 <br /> (209)468.3420 <br /> NON.REFUNOAYLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempleteIn Trlp6este) <br /> IPUCATION IS HFTRFRV MADE TO THE RAN JOADURI COUNTY FOR A PERMIT TO CON6TRUCT ANDIOR INSTALL THE%ASW DERCRIOED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> AN COUNTY DEVELOPMENT TITLE CHAPTETR 9-1110.3 APA HE STANDARDS OF AAN JO IN COUNTY PUBLIC HEALTH BSE/�j�yt�CER ENNVVIIRONMENTAL HEALTH DIVISION. <br /> DORESRIOR A— ���/�c CITY ✓ 'w"�}'O '7�L O]T SRE�T G� <br /> NNER'S NAME �`L ADDRE S! J/ L C / VV T4IONE�7S�I�47 / / <br /> *-�"RACTOR'440'�� '-�L_ ADDRE9Sr2j (� � ,•/( J -�k LIC,M,PH0NE!�y� <br /> ONTRACTOR ADbREe6 UC, PHONE <br /> IK OF BBPUC WORK: NEW INBTALLATTON WFAIRMODITION❑ om TRRK:T1oN❑ <br /> O SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AV AMBLE WITHIN 200 FEET OF AUILDING.I 1 J t Pt31t ITS TH1 1 1 HOW MANY <br /> ,LIATION WILL TERVE: SIOENCE❑ COMMERCIAL❑ OTHER <br /> APPIIeBSon <br /> AJtYER of LMNo I. NUMBPR M BETNOOARB: E NUMBER OF EMPLOYEES! <br /> OF ROII TO ATTDEPT7�1 OF 7 FEET Q�. F'TT!(yUEAP BOIL CHARACT WATER TABLE DEPTH 1 <br /> TA ILII TRIP ❑TYPEWFO `J_I•V CAPACIT�C) NO.COMPARTME/�fT^B� <br /> REATMENT►CANT 11 bleTANCE TO NEMRST- WELL �@�_ FOUNDATION S� I P—PI:Rr a LINE <br /> LIFT STATION Cl SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED 9YSTEMI <br /> / <br /> 'ACMNO UNE J bNO.a LENGTH Of UNEB �"�� ( "—X RE <br /> DISTANCE TO NEAST:WELL_l� 'l FOUNDATION (0 _PROPERTV LrW <br /> 1 T9R BED ❑WIOTN LENGTH OEPTH D19'TMCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> VOID ❑WIOTN LENGTH DEPTH DISTANCE TO NEAREBTI WELL FOUNDATION PROPERTY LINE <br /> %OE PTA �DEPFN,2C <br /> SIZE LT NUMB ER_DISTANCE TO NEAREST:WELL POVEIDATION POI PROPERTY VNE Z / <br /> JMPS (]WIDT14 LENGTH DEPTH GIST ANCE TO NEAREST:WEU.__FOUNDATION PROPERT UNE 9— <br /> SPOBAL PONOS Q WIOTN LF.NOTH DEPrH DISTANCE TO NEAREST:WELL, FOUNDATION PROPERTY LME S <br /> Q <br /> EBY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE W WILL BE DONE NI ACCORDANCE VRTH BAN JDAOUM COUNTY ORDINANCES AND STATE LA—R.AND RULES <br /> aEGTRATIONR of THEBAN JOAQUIN COUNT.HOMEOWNERORUCENREO NTT SIGNATURE CERTIFIES THE POLLOWMO:-I CERTIFY THAT IN THE PERFORMANCE OF THE WDPK FOR WHICH <br /> ,.lPESAIi IB ISSUED, BNA OT EMPLOY A N IN SUCH A MANNE A O BECOME BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S NH11N0 OR <br /> JP-CONTRACTING SIGNATU C EB OLLO 0:'1 CERTIFY THAT I THE RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IRSUED,1 SHALL EMPLOY PERSONS SURJFCT TO <br /> IOWMAN' OM R ION CRIB OF A F IA.' TI APPUC ANT MMT ALL 24 LRB IN ADVANCE FOR ALL REOUIR i MSPECTIONB, COMPLETE DRAWING BELOW. <br /> ID X TITLE• ` <br /> ROT FUN RAW TO BCALO SCALE 'M / <br /> NAMf,B OF BTTIEETB OR ROApR NEAREST OR SOUNDING THF.PROPERTY. 4. LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR POPOSEO <br /> ^UTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DBPORAL SYSTEMS. <br /> vAENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, e.LOCATION Of WELLS vwTHIN RADIUS OF ONE HUNOWD FIFTY IT.ON <br /> CLUDINO COVERED AREAS SUCH AS PATIOS.DMVEWAYB,AND WALKE. THE PROPERTY OR ADJOINING POPERTY- <br /> ... ... ' <br /> ...... I. .. . <br /> (.... v <br /> : ............ <br /> ...: ......... . .. <br /> --;a�a <br /> . <br /> _ <br /> ;.... <br /> :. . ........ e <br /> ......:.... <br /> . . <br /> .. <br /> 3b I <br /> PAYMEN <br /> i <br /> s <br /> ... ....:..... N 2 0998. <br /> y <br /> . `.. .. ... — OUIN-COUNTPUB <br /> K . <br /> S i ... ......:. ... . .......... .. E yIgONMEiNTHt.1"t+. <br /> .. FALI <br /> FOR DEPARTMENT URE ONLY <br /> C DATE: AREA! <br /> p <br /> 'PLICATION ACCEPrED OV —4 G <br /> DATE / / <br /> FINAL INSPECTION BY DATE <br /> ,•NS,PIT OR RUMP MRrECT10N BY <br /> ADDITIONAL COMMF,NTS: <br /> ACCDDNTIND ONLY: <br /> AID, FACT <br /> .R PE COD£ INVOICE, <br /> FEF INFO AMOVNT RETIITTEO 3Z( I/CASH RECEIVED BY 0 BR I PEtuM1T N <br /> LIMG <br /> 10/05/2004 TUE 14:57 [TX/RX NO 76101 [ 005 <br />