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APPLICATION FOR LIQUID WASTE PERMIT JOAQUIN COUNTY PUBLIC HEALTH IVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 Sd w to c, Rd (209) 468.3420 f NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Q 5Z 7-"C) ICPmplot+In TFtptk.l.) AMT.ICAI ION IR PIFRFSV ADE i 111E RAN JOAOUIN COIINTY FORA PFnMiT TO CONSTRUCT ANDIOn INOTAl .TIIE WOTW DESCRIBED. TIIIR APq)CATION IR MAnF IN COMMiANCF.WITH RAN JOAOUIN Cn11NTY OVAtOPAIF.NT TITLE.CHAPTER 9.1110.3 AND TIIF.RTANDAMS 0►PAN JOAOWN COUNTY PUBLIC NFALTN SERVICES.ENVInONMENIAL NEACTII DIVISION. .InR AnnnEnnion ArIll d O 7 —/ 3-V 2 CITY 1Q / IDT P1711 T. OWMI'"ll NAMF��/ An.I FO%p 3- lD ►t��a !�•�I(At'-V-�/- ►�V!/ �,�{F ��'l 104 / �] -1 C ONT nACTOn r. �1 \� ADDnF..RR��alyl;-Afyaft C6 Rc/•, II(C/_—T mfON Q7-/J_"-./ t/ _-- RUR CONTIIACTOTI AnnnFPll_ �G'` ' 61I `a . gsL-1 PRT•/ P/IONF TYFF Of AFPTIC WORK! NEW INSTALLATION ❑ RFPAin(AOOITION ❑ DFPTnue'lloN❑ INO SEPTIC RYRTEM PEnMITtEO If"mLIC @EWE"19 AVAIIAOI-E WITIIIN 700 FEFT Of RtlltolN0.1 PMC TEPTI.11 1 FLOW MANY �-•• AnPP"rdop/ �-_o a� INS LAI lAT10N Wlll SERVE! nF BIOFNCE❑ COMMFII:IAI. ❑ DTII►R ❑ NIMARF"OF IlVINO IINITA! NUMRLat OF RFDnOOMP: NIVARM OF N AM-OYFFS: CIIAnACTEn Of @OIL TU A DEPTH OF FEET! PT/Rl1MP ROIL CNAnACTEn: WATFR TAKE OFPTN PFTTIC TANKIOnFARF.TRAP ❑TYPEII,IFn CAPACITY NO.COMPARTMFNTR MIT InFATIIIFNT 14 ANT❑ DISTANCE TO NFMFRT! WEIR. FOUNDATION PTIOPFnIV UNE IS'T STATION❑ 917F. TYPE OF"IMP RAND OIL @FPAnATOn IFNCI ORF"SYSTEM) 1 FACIANO UNE ❑ No.A LFNOTII OF UNEP OIRTANCE TO NFAIIERT!WELL fOIINOATION PIKU'FRTY IINF ►itiFT1 RED ❑mom tFN0T11 nFmII OIRTANCF TO NFATtF@T!VMt ►OUNDAMN PROPERTY(INF_ MOUNOEO ❑WIDTII tANnTII OF.PTII DISTANCE TO NEAREST!WELL FOUNDATION I'llo"WTV UNF. AFFPAOE MTS ❑oEPTII SIZE NUMBER DISTANCE TO NEAnEST!WELL FOUMOAT1oN P/IOPFITTY IINF SUMI'A ❑1MDT11 tF.Nnill DFPTII DISTANCE TO NFARFRT!WEU, FOUNDATION P►I1PERIY IINF OIAPOSAL►ONnS ❑WRYTII tENOTII DFPTII DIRTANCE TO NF.AIIERT!WELL ►OUNOATION PIOPERTY LINE. I IIEnFIlY CERTIFY THAT I IIAVE PIFPAnEn TIIIR AMICA71ON AND 711AT INE WOIK WII L PE MME IN ACCOnOANCF%VnN PAN JOAOUIN COUNTY OMINMA:FR AND RT ATF 1 AWA,Atin nIR FR AND MOULATIONP OF TIIE PAN JOAOUIN COUNTY.Nome OWNEn On UCENPED ADENT'S SIONATUPE CEITTIFIER TIM FOLI.O%MNOt'1 CERTIFY TIIAT NI TIM PEKOIM/ANCE Of T11E WniW fon""Cif TIIIP PEnMFT IP 1PRUEO.1 m1ALL NOT EM".OY ANY PERSON IN @UCII A MANNER AN TO BECOME SUBJECT TO WOPCMAN'P COMI'ENSATKRN IAWS OF CAIXORN1A.' CONTRACTOR'S 111tS11O On BUO-CONTRACTING RIONATO"IF CFRTIFIEP TIIE FOLtOWINO!'1 CERTIFY THAT IN TIIE PFRFORMANCF.OF TIIE WORK FOR WIIICII TMS PEMUT IS IPRUFO,1 MCMI FM"OY P6nRONR RtIR.IfCt In WOTKMAN'R COMPENSATION LAWS OF CAIIFO TOPIC APPLICANT MUST CALL 74 040tOnP IN AnVANCE FOR Alt REOUInFp INSPECTIONS. COMPLETE RIIAWINO R61.OW. t @IntIFD X - � TITLE: I IL nAi F! �_ �y M.OT"AN R1MW TO @CALF)PCAI.F._ •1w 1. NAMFR OF STREETS On ROADS NEM RT TO On ROIINOINO TIM PROPERTY. 4. LOCATION OF NOIIRF PTWAOE 012MRAL.RYPTFM on MRnMPFn 7. OUtl-INE OF TIIE PROPERTY.WITH DIMENSIONS AND NORTII DIRECTION. EXPANSION Of PEWAOE DISFKORM PYRTFMR. J. DIMENRIONEO OUTLINES AND LOCATION OF ALL EXISTINO ANn PROPORED RTRUCTURFS. WELLS WITNIN RAD1UR OF ONE NIINDIIFD FSTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS ^""^-'"'•"' "•- "'- / _ l/ )DINING PnoriFRY. I DESIGNATED REMAINDER STI , PARCELI �n Ie A.:" — V/ I J,PARGEL 2 — PARGEL 3 UNDERWOO D APR 6 r r ....... .. ....:.......:......;.. ...:.....:......:... :.....�'NVINr'F�I(;111;IR11 y SFII�p 11 i c F n nFPAPTMENT USP ONLY Af-MICA110N ACCFPTFD RV l ki "AYE- L AREA- TAW,PIT On PUMP INBPf CTION TOY DATE / / FINAL-INPPFCTION BY OATF ATIUIT TONAL f,OMMENi B• l�jl /n "/ �/ ISG e /S ' 'Y<.r'~==1L2L� rACCOUNTING ONLY: I AIM ---_- -- FAC/ PF COOS ►EEINFO AMOUNT REMITTED CIIEC 1CASI1 RECEIVED RY DATE Sn/PFTPWT NLwim INVOICE 2� ?, - ):tet O Pub.HBBIIh SBTV.-Envlro.174(3/9R) /)