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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONp7; 304 EAST WEBER AVENUE,STOCKTON,CA 95202 r/ , (209)1468-3420 MON-REFUNDABLE PIM EXPIRES 1 PEAR FROM DATE ISSUED ICABSIEIA In TTIPAPAt l APPLICATION a IERFOV MADE TO THE BAN JOAOUM COUNTY FOR A PFNJN TO CONSTRUCT ANDIDR INSTALL THE WORK DE/CNEEO. TiB APPUCATON U UADE IN COMPLIANCE WITH SAN JOAOUN COUNTY OEVELOKWNTT TRTELC�NARER 8.111'(03/A�fRQ)T�H,<E^STANoAA�FM-�1}-OAF N JOAO COUNTY NALIC MKrN w^MEIL[N 'FIUENTAI HEALTH OMNON. JOB ADOREBSSOR A`NF rr(� r'�n{CJ ;�] Ir1� f 1 l-.1{I V{ CITY �1p l4T 112E OWJNERTI -V 65' L 4-F-9 r O/` �Ii iLVW c AODRE.. �--8a 21 �-,f r�C-r'�-o W t' 15205- �1 k 3-?243 OON TACTOR, _Wl V -LC f" ADDRESS A-1 Firk uC, )L pw#4-7iL 104,4- SLSI CONTRACTOR ADDRESS VCT %RHONE TYPB OF■- `OF IC NOW INSTALLATION❑ REIAwADar10N❑ DVTMJG TO NO CEYTIC SYSTEM PfFU TIED IF P'.ISLIC.EWER IE AVAILABLEIT WHIN 700 FEET OF BUI)IHG_I 1'EILL•TBSTfiI I 1 WJW MART APFS�bn I_ INSTALLATION WILL SENT: REIDEICL❑ COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUASFN OF EMPLOY9J: CHNIACTER OF EOE TO A DEPTH OF O fFET:- PT/SUMP BOIL CHARACTER: WATER TASTE DERV SEPTIC TANRAOREAR TRAP, 11TYPFJMFO CAPACITY NO.COMPAPTMBFT9 MO TREATMENT PLANT 0 DISTANCE TO mumt,T: WELL FOUNDATION PAOPERrY LINE UFT STATION❑ BRIE TETE CF PUMP SAND OIL SEPARATOR EHCLOSED BYSTEMI LEAOMMG LINE ❑ NO.A LINOTH OF UNFE_ DISTANCE TO NEAREST:WILLFOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENDTH DEPTH DISTANCE TO NEAFER:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENOrH__OERN DISTANCE TO HFAUEST:WELL WUNDATDN PDF[RTY UNE SEWAGE RTS ❑DEPTH @WE NULIBER DISTANCE TO NEAFE-:VAn FOUNDATION PFQPATTY LINE SIMM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAINEST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONOS ❑wom LENGTH DFPTH DISTANCE TO NEMRSTI WELL_FOUNDATION PROPERTY WE 1 HERESY CERRFY THAT I HAVE PREPARED TMS APPLICATION ANO THAT THE WOW(WILL BE DMFS IN ACCORDANCE WITH SAN JOAOUIN COLBFTI'ORDINANCES AND STATE LAW'S,AND ARLES AND NEOLAATIONS OF TIE SAN JOAOUIN COUNTY.HOU!OWNER ORLICELJBED AOFM'B SIONATURf CFRrNIES THE POLLO'AAIO:-I CERTIFY THAT N TNI PEPPOIM.WCE OF THE WONT FOR WHICH TWO FERRET U N WED,1 SHALL NOT EMPLOY ANY PERGON N SUCH A MANNER AF TO BECOME SUBJECT TO WORKMAN'S COMR[NLL\TION LAW'S OF CALNORNBA..CONTRACTOR'S HAEMO OR SU& N CONTRACTG SIGNATURE CERTNEB THE FOLLON/INS:T CIMIFY THATIN THE PERFDFMANCE OF THE WORK FOA WHICH TMS FERMIT IS ISWER ED,1 SHALL EMPLOY PSONS SUBJECT TO WONCMAWN COMPENSATION LAWN Of CAUFOMSA.- THIS APPLICANT MUST CALL LV NOW IN ADVANCE FOR ALL REOUNID IRSPBOTIONM. COMPLETE DRAWING BLLOW. lJ saNED X ly�� TTTT-E:_ DATE: va u PLOT PAN OPNW TO BC ALE)SCALE 1.MAWS MTR STREETS OR ROADS NEAMST TO OR SOUNDING THE PROPETY. la.,LOCATION OF NOIROT SEWAGE DISPOSAL SYSTEM on PIDPOSED T.OLlTUFN OF TIE PFIDPERTY.WITH DIMENSIONS AND NOIAH DIRECTION. EXPANSION OF SEWAGE O16MB.AL BYSTEMB. O.DVANRONED OUILNES ANO LOCATION OF ALL EXISTING AND PROPOSED STRUCrUIES, S.LOCATION M WELJO WITHIN RADIUS OF ON!HUNDRED FIFTY PT-ON INCLWBO COVERED MEAS SUCH AS PATOB,DRIL'EWAYS,AND WAUCS. THE PDPE/1TY OR ADJOINING PROPERTY ' ...... _ : -------------------- .......... .. . _ .... .. ...:.................• - _ «_ .. ........... ........ ..... `v............. ........... p.............. .. EyiVC.IANU ;\ +itiLL ............. �..._..... _ qEC . ^ .. ........... : _.:......_ Q6UN7Y .....: .. ... ._.:....:... .......«......�. .>......i . .... .... ...... ..... .... ASTM II{+ jjV..:.. i i ........... ..... :....... .. ....• 5.....;.EIfN1F�N.R'IF.NTaL 3 - 1�� ONLY . AI4LICBilly a T� ArroH ACC".. GATE: � •(j( �`-'o ANFA: TANK,M OR BUMP INa/ECTIOIJ SV DATE ! / FINAL INSIECr10N 0V - oIRTE r; , ADDITIONAL COMMOITS tod TLTJ 5o5fl.WA6 qkf 5•SHF ACCOUNTUO OMLY: NOr PACT PF CCm FEE INFO AMOVHT RBIAIT NEC MASH mircitivTo By DATE M l WEBMT NLEISIM INVOIC!S Pub.F4*SMl SON,-Enviro.174(3/98) / f�