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APPLICATION FOR LIQUID WASTE PERMIT 1c SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (� (209)468-3420 n OL9 NON-REFUNDABLE PERMIT EXPIRES 1 YEAH FROM DAT!113M 1 IOmryb l. In Triplmtfl (a f 111 APPUCATKHI Ll HEJEBY MADE TO THE BAN JOAOUM COUNTY FOR A PE/AIT TO CONtTRUCT AN WOR INSTALL THE NVR(MUDDED.TMI NRICATION 14 MAGE IN COMPLIANCE WITH BAN JOAoLAN COUHrY OE4EWPM/EJNT rrTLl.CNArrER 0-11110.33 AND 1�NE�STANDNOB OF A4N JOAoM COUNTY PUBLIC HEALTH SER/VVIIjC.EE/&EEHVM OWADrTAL HEALTH DMISIONC.-_ 31 3� JOS ADDIIEewoR AOH// C/q J O f 1 L/V/SCJ /V� CITY J 1 O E/LOT 012E ONlm...ME (�7F'L+ fIC'/iYCOit 1'''�FW"t(.G _ADaEee .Z`id4 G`- FKCr--6✓►', --yfMIC+W.0 �t �3'77�3 OWFRACTOR C EN+r.0 4L y P1(.,L�f ADDRE66 e 1 0C L AtAN KO uc/,J W4 6 L y LisPUP CONTRACTOR ADORE.4 UCP RONF TYPE OF 41FIM WORK: NEIN ITMTALLATON❑ AONNADdrIOM❑ vu— SIO tEPTIC WIrTET4►FIADTTED F tVR.IC SEWER 12 AVAILABLE WTTHIN 200 FEET OF SURVINO.I P%PC TESTI.)I 1 HOW MANY AFPB�SEA/ INSTALLATION WILL IBRVE: RESIDENCE ElCOtFMEF"AL❑ OTHER❑ N1/iMR OF LvAw UNITS: RUM!BI OF SImNOOMf: NLMMI OF AAFLOYRLI: CHARACTER OF SOL TO A DEPTH OF 3 IFM:_ IUMP PrrISOIL CHARACTER: WATER TALES OEFTN EEFTEC TANKAWWAAE TRAP ❑TYPEMF.O cAPAGm No.COMPARTMENTS MG TREATMENT RANT❑ DISTANCE TO WARM: WELL FOUNDAAON PROPERTY LIE UFT ITATION❑ SEM TYFF CF PUMP SAND GA.SEPARATOR aWLDSW trlTIEB LEACNNO LNt ❑ NO.A LENGTH OF UNE._ DISTANCE TO NEAREST:WELLFOUNCIATION PLIOFENTY IDE FRTEi SW ❑N1pr11 LEHLTTN OEFTH OIITANCE TO NEAREtT:WELL ROLFADATION POPERTTUNE MOUNDED ❑WFUTH LENGTH__OMN dfTANCE TO NL-ESTI WE7.L FTAMDATION PROPERTY LAE IeAGS RTt ❑DWT1 I ZE _NUMBER ORTANC2 TO NEAMM WELL .FOUNDATION PROPERTY MR ILMFR ❑WRITE URUM DWTH DIBTANCE TO NFAIEIT:WWLl _FOUFOATIDN PROPERTY UNE 010F04AL 1`60100 ❑WI)TN LFNOTH ,DEFTH DISTANCE TO NFJIKBT;WETLY__FQ~TFDN PROPERTYIINE 1 HEREBY CERTIFY THAT 1 HAVE FREPAJEO TMS APPLICATON AND THAT THE WCRL WRL tE DOM IN ACCOADAWE W17H"N JOAOIAN CDWay oMMAW"AND!TATE LAWS,AND RULES AND REGIAATb/HOF THE IAN JOAOLRN COUNTY.HCHA OWNER ORLIC BYIED AGENTV LOONATURE CMFW@ THE FOLD IND:7CERTIFY THAT IN TIN PEONRAMIC E OP THE WORK FOHMASCH TNR PFIAET It MWM I MAUL NOT EMRDY ANY PERSON IN INCH A M41NM AN TO BECOME VJWELT TO WOR IAN"COMPWIATION LAW@ OF CAIAOFFRII CONTRACTOR?TSIMR OR 91.16,MMTRACTMO tkwmTUIV CERTRiE1 THE FOLLONANG;9 CERTIFY THAT M TOE PFPFORMANCE OF THE WORK MA NTICH TTOS PENNT R RSUEM 1 SHN1 EM"�Y/SROM EUAJE'CT TO WOEKM/W`5 CokVIENtAT%1N LAW!O]F/CALIFORNIA.- TILE APRMANT NWT CALL 26 NOLtR IN AOVAMCK FOR NL PIDNAROD WIPWVWM- COMPLETE DMNA"INE^W MO1ED% IV�YI•l ./ /!i V PLOT RAN IDRAW TO 4CAUn 4CALE N 1.NAALEt OF VrFEETS OR RDADf WAREST TO OR DOIN�NIO THE F'110F f". 4.LACATION OF NOOSE IEWAal DRBOfAL IYWIM OR PIIO1`0IED 2.OUTL.E OF THE PROPERTY.WITTI DIMENSION"AND NORTH DIRECTION. EXPANSION OF RWAOE DWQGAL SYSE7lAI. 3.DIMENSIONED OVTLFEt ANO LOCATION OF ALL EXISTING AND PFIDP04EO WrRICTUREG, 4.LOCATION OF WELL WITHIN RAORIB OF 014 HUNDRED FIFTY R.ON INCLUDING COVERED AREAS IUCH AS►ATTOt.ORVEWAYC AND WALK/. TTE PROPEPRY OR AD.AEIBPG FROVERTY. ... i......... i i i ... ... ... ........ ..... .. ..... - ...... - • I : 1 1 I, l .. .... '.....n.........:.......... i........ .: .. b .......b......:...... ....«4.....:..... ....... i ....: ................�.-..... ...:.... 1/ s .. ...:.. `....:......:.....i.....s......1.... : : . ..:_... ....:....... F..........'... .. .i ....:....o....:.. ..._....._,. ..:..... ....... nIV1Y1G�, .. .. .>... ....;..EN RONM NTAL MSH N 8hN,1UAflUI ... .. ` //-Q� rte.. o _..PFJ(OpjIR(yppMTllfiNT YY ORRY 6,/�JfI'//►yV AFFIXATION ACCE9TEO B'+' L.l C 1 (/�/�G( \ _ DATE J=�f--•—•— TAIL,PIT OR SUMPINstLT10N BY `t'��/7 �}__DATE ! /C/ FINAL INSPECTION BY DATE ( J ADOITIONALCOMMTNT31,qAZ 5171 lZ4"T-• Yµr1 7 �/ T' 114* •- ��aL��RFTT17 40#5 f N C6 -Y-oz Sy 5. 51y!,41 — 55 LVLe�,DN•[X'T1�/►••�4 — 64 ADCDIWTING GREY_ ANOJ FAC/ PEC00E Fff INFO AMOVNT TUONIITOP CI TEC MAN- D15 AOND 5 Pub.Neel h SerY.-Envim.174(3188) � _