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APPLICATION FOR LIQUID WASTE PERMIT <br /> _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> MON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> y MBRP6t.IN T,iPf MI <br /> A CATpN M HEKRY MADE TO THERM JOAWIN COUNTY FORA MIWR TO CONSTIIUCT MOOR INSTALL THE MW TMB IPflJCATpNI6 MAGE d CONNVANLF NTFN BAN <br /> M,.COVHTY..HNT TITLE, MV CHAPTER R-1110.]AND THE WTJJID� mJOA <br /> . dIIH FVe1JCHEALTN6�EB,FNNXJMMEMKII'MTX pNWN. <br /> JOB ADORESAA R//A^y.,,� Z99 CS' L'^-'/�T_L_Y/Ee J /C/f(/EJ/ E,T.T N.�/M 2 LOT <br /> '� OWNEP'.NAME I( /T�V AWRERRy/��/� //"LI - .�'�jf daNVb9�j373[0 <br /> LONTMCTOfl /✓•K TT�//�r•'-//��G ADpZ66 l�� �!i4LIC, /rTGL� RNHF '!'��3• <br /> 6VB COMRFL o • ADD11E66 LICI MWNF <br /> TYPE OF VFMC WOR(: MEW dWlAWl10N❑ RVMWAOd1pN OF•111VCTWX❑ <br /> Nq SERIF eYSTp1 PENAITTED R PVOLO SEWER M AVANABLF....E.MET OFB HO.1 F61C TflTb111NOW MANY <br /> AWisCw, <br /> INFIAWIION WILL. MSTENCE COMMEICIAL❑ TNER 0 <br /> NI.Med OF INNO 1MfW: NIISWLII OF OFp10OMB' MMO610F MROY[d: ,./ �J <br /> r CHMARM OF 60A TO A DEPTH OF]FEET: LA✓ATMIIMP 600.CNAMLTFfl:C AT U WATFII TASTE DEF,H <br /> ..TAN..TERM ❑.,. CAPAET' NO.COMPAMMENTB <br /> FRO TREATMENT RANT O d6TANEE TO NFMFET: WELL- IOVH.ATWN M10MRTYME <br /> LTESTATONO BOB TYPE OF PIMP 4. '6AJA OR.dI.T..MNE..SYPTEMI <br /> NO.B IH OFY /TspBTAE TO..RT,M � OA"" <br /> AMHODxE ME /- <br /> ' WVMRIY LJME �S J <br /> FLTF11ePo 13 ,rH tMISTH OERTH�DISTANCE TO HEMEST:WELLFOLINOATONFROMRTYLBO <br /> MOIMOED FUy. IENNTX RFIN DIM <br /> StANCE TO NEAREST:WELL fOVNDATMN-FMRTY LME -J^0 <br /> ...E WT. J,_a RF,M�ERE��O IY "Of. E dk ANCE TO NEMFOT:V��PoIMDATON�FLOMRTYLME 2 A <br /> _ BVMfi E❑WR,N LEMOTN OEFIN._dBTMICE TO HEAREET:WIIL�PoIMOATON�MOMMY UNE <br /> diroSAL P... ❑YAmN LENGTH BOTH�ONRTANCE TO NEAR6T:WELL-PoWELAIONMOFERIY Lwk <br /> MEMSY CEXTNY THAT 1 MAW WFPAISO TRS AWIICAT H AND THAT THE WdR WILL RE GONE W ACCORDANCE WEM iAN PA..COVNTY OMNMMCEB AND'ALL IAVA.AHD ROLE. <br /> Np WEONATONe Of1MeFN AAdIMCOVMY.WME� NERORIICENBEOAOEM'a MONATVPECFRTIfNBTNEfOLLOW1N0:•ICFIRIFYTXATMTMEMWOIMAHCEmTRACTO PoRINGOR <br /> TIM WAWT MISSVEO.Ip1ALL NO EMWOYANY PEIIBO NCM A MANNER M TO BECOME EVSIEm TO WOW(MANY COMMNSATON 1.OF CAIFCIWIA.•COMMCTOR'S RNNS OR <br /> IIRLOM e0' TOM TIES THE FOLLOYAN :'LfATIFY THAT M THE IEWON.LMIEE OFTM WtlIW fOfl NN TMS MRAR IS IBNEO.I BNML EMMOY MASON["E'T TO <br /> r NOIR eCOM E T N O ALFOBN YCABT�MV{T CALLMIVVIIeMbVANCEiM ALL MO 01M6MCl10Ni. COMRFTF dMWIHO SFIPW. <br /> Ftm OMw TO 6CALM SCAIE <br /> 1.xMRB OF elllETe OR RJAOS xEAMAT lO OR SOIJIIpNM TR POMMY. A LOCATON OF xOL.E d .F pwBM rvREM OR ProFOSED <br /> f.OPTIVE OF THE WOPFF,Y.WRM DIMENSIONS AND MONTH I.CT.., EXIANNON OF BFNAOE M..BYETENC 1 I <br /> S.OSAENWONE.. .AND tPOATON OF ALL FORT..ANO PROPOSED 6TPVCTYP£6. 6.LOCATON Of WELL...--OF ONE XUNORED NFIY FT.ON <br /> INCNM <br /> BO COlE1R0 MEAS EVEN AR PAM....A'. <br /> AND WAIVE THE PROPERTY OR ADMBEHO MOMMY. <br /> i <br /> 15 Lit �IPVSC <br /> 4 <br /> ENT <br /> SAN JOAUUIN CO Jlr <br /> -PUDLtC91:AlFM BC ICP9 <br /> ENYI(NNEAENTAL HE.}LT DIVISION <br /> 1 <br /> fOP OO'MTMRT VSE ONLY <br /> R A ON A CFMFD SV DATE: z r z <br /> TAMP. OR BVMP M.PFCTOII BY <br /> PATE, <br /> INSPECTOR <br /> SV DATE 3 12 , <br /> App}OHM COMMFM 6: <br /> COVNTXO ONLY: MOI FACI <br /> M CODE MNMO ...NOAIT. CL.KE H .1c..Y PATE M/W3P11T xlMBOI OOEI <br /> i <br /> Pub.HBBRb Serv.-EHA.,174(MG) <br />