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APPLICATION FOR LIQUID WASTE PERMIT <br /> SA1F►JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC{R,ai.t{is TIrGnI.l <br /> ARTICATION IS/FEMBY MADE TO TIF SAN JOAOUIN COtM FOR A PERMIT TO CONSIFEIRCT AND/OR INSTALL TNM 11q(K DESCRIBED. TM{ARLICATEOM H MADE BI CDMRIANCE" <br /> JOADL/M COIINFY DEVETOR.IENT TTnl-Cl1APTER 9-1110.3 AND TIN:STANDARD{Of SAN JOAA/O COUNTY MOM/1EALTH SEERVVK�E{{/�,jEMI ROM.IENTAL NEA1.1E DIVISION <br /> JOB ADDREGSOR AEN/ �1 /O//T���_L/_ - /GG�L,r�Lr /�-r11' CITY (,-Y/56 LOT SIZE <br /> OWIIMA'S NAME-/'��/' `Z'C"�-� -// ADDRE59 //14WD'I/ In <br /> yz <br /> COMMCTOR✓v�� 'F"L _}c..7'J G AGGRESS/ l �•" . �C RgllE <br /> 6—CONTRACT" e+ ADORES. lK/ RIONF <br /> TYPE OF eFTTIC WORK' M[W M.IALIATION 11EPAMVADd IFON❑ DFa TALICT-.Cl <br /> {JO SEP SYSTEM F4WAITTM F F ID13C SEWER 16 AV BLE YWH.N 300 FEET Of RlAD1NG.) RAC iRTMI l 11IOW MAMY <br /> 'J Ap{beaR <br /> W[TALIATON WRL.E - RESIDENCE❑ COMMERCIAL❑ OTIIER❑ <✓� _- <br /> NLIM.DL OF—..—IS: / NLMBER�'of,INDROOMS: Nl1MSER OF 9AROYEFI: <br /> ` <br /> OF 500.TO A DEPTH OF]FEETC- N� T!$t/MP 60.K}�CHARACTEA:1fTlY�T.��/f�t�^- WATER TABLE O 14 �C <br /> pTM TAN E TMF ❑TYPE/MFEe'H _SCJ CMACETY �Os��� ` NO.COMf`AIFEMETRS <br /> TM[TIT RANT❑ DISTANCE TO NEARFiT: MAIL � FOUNDATION`' 3 PEIORRTY L1NE���/ <br /> 11FT{T ATON❑ SIZE TYPE OF Ml tP SAND OR SEPARATOR{ENCLOSED SYSTEM{ <br /> ' IUCHMO UNE NO.a LENGTH OF LINE./-4/0 iE-C dATANCE TO N[AItCRT:WELL(�B FOUNDATgN,/0 ET FTY LINE /-O—e <br /> FILTER SID ❑MOTFI LENGTH DEMN DISTANCE TO NFAISST:WELL FOUNDATION{ RUOF4RTY LINE <br /> MOLMDED .�❑E MDT" LENGTI OEPTE DISTANCE TO NEAREST:WELL f01MDA71ON R10RRTY tNE <br /> tEEPAOE RTa DEPTH 2�WZE �3(��/ NLIMBER�_DISTANCE TO NEARE.T:WE11�nO E TOUNDATgNS0 RIDESRTV IJNF OUB <br /> t11AP{ ❑—7" LEMTII DEMH DISTANCE TO NEAREST:WEll FOLINDAT"ON —KmY LINE <br /> DI.PO[AL POND{ ❑WIDTH LENGTH M-H DISTANCE TO NEAREST:WELL FOIMIDATION PRDPEEFTY LINE <br /> — <br /> I NEFR BY CERTIFY THAT I F9 PARED THS APRICATONI AND THAT TIE WORK WILL BE DONE EN ACCOFOANCE—I.RAN JOAOUM COUNTY OImINANCEB AND STATE LA—.Al <br /> AHD Ia<OVIATgNe OFT t1AN A COLMTY.MME OWNER FNBED AOEM'S SIONATA ctmwxS TIM FOLLOWMO:ICERTFY TEAT M TIM K EFOHAANCE Of TEMWOKF <br /> TMS RH-{T IS ,1 SIAL OY ANY FLASON M 8110A <br /> R A.TO SECOME&M MCT TO WONCMAN'{COMIFNBATKIN IAWa OF CAUFORHA'CONTMCTON{t <br /> _ St/6CONT AT AT THE to 10 T M TIR RAIORMAN,E Of TIM WOW FOR VJNICN TINS PUMT IS IBBUED,I S/WL FMPLDY RRDONS SUI <br /> WOFKMAFf C T C A. 11E ANT CALL 3—L Rj;M ADVARCE FOR 1/A/LL,{,"RE MSPECTpNcomm <br /> ill COMFTE DRAWNIO BELOW. /x+ <br /> TIRE- \ DATE �✓— t/ <br /> SIGNED% <br /> ROT RAN RIRAW TO—AIXI SCALE_ <br /> Lo <br /> 1,NAMES OF SIREFT{OR FIO TO DR BOUNDENO TIF PE IPERTY. a.LOCATION OF NOV eE SEWAGE DISPOSAL-VIII OR PRIOR <br /> 3-DV oW Of TIF RIDPERTY.WITH DIMENSION'AND NORTH DNEMCTION. EXP TIONEoDN f 6FULt THtN RA <br /> 1{YBTEMS- <br /> 3.DIMENSIONED OlfT1AFES ANLI LOCATION OF ALL EXIRTMO AND PROPOSED STAWTUIFIE6, G.LOCATION OF WELL{NIT/RN iV1TM)t OF ONE""Non'""T <br /> MCLVD.O COVERED MEAS RICH AS PATIDS.dMWAYS.AND WALKS. TINE PIgRRfY OR ADJOe RIOPERTY--_ <br /> v, X <br /> - N _ <br /> t <br /> �nF <br /> PAYMENT <br /> JAN -69 <br /> 198 <br /> _ _. .. SAN JOAQUIN Cr <br /> uNly <br /> .PLLSUCHEAL1-N SEFMCES <br /> - EIJVIFION <br /> WNTAL HEAt r, <br /> FOI/L//7DFPAPTMENT USE ONLY <br /> J/ DATE: / —/3FA: <br /> L —J'— <br /> ARCATION ACCETTED <br /> BY NV / l � / C <br /> �DATf, I / FINAL INSTECT ON BDATE I <br /> V , l <br /> TAMC,PIF OR SUMP MWECTION It <br /> A1RMtgNAL COMMENTS: <br /> ACCO VNTMO ONLY- <br /> AID/ IAC/ <br /> PE cODE FEF INFO AALOUM IGMITED CIMC ABI RECEIVTD{Y DATE M/FTAMIT MVA{ER INVOICE/ <br /> )Ic. q� s8� D y83 <br /> Pub.Heattb Sol.-E-110.174(3/96) <br />