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APPLICATION FOR LICUID WASTE PERMIT I <br /> f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICFS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388, 446 N.SAN JOAQUIN ST.,STOCKTON,CA 95201 0388 <br /> (209)488 3420 <br /> ROM REFLIND(IpEE EMIT EXPIRES 1 YEAH FROM DATE ISSUED <br /> (Caw,M.In Tri►IkaN) <br /> AAlICATgN IS IMRf RY MACA TO TIO BAN JOAIWIN C.1.UN11 1011 A IK WAIT TU CONSTRUCT.ANDOP 11:8TAII tllf MATO 1H SENRIII. TNI&APNIICATION IS MAIZE IN COMPLIANCE WITH BAN <br /> J JOAWMfOVNTY INVII0I MI NT.TIF CMAPIt110 1110..3 AND TTI)RFSTAN:IARD.1- bAll lOAOUI 1;011NIY'MIRIA:NIAIIII SI 18'FftV'AONMfNTAL NI At TH pNGON <br /> U�uR AU711[SBNA AI/�C��/�J k /�l/�1�.'�(Y/nV�/�i�c{��-Y �� f.ITY-,�1�!lF A LOT SII[{�j[(� <br /> /_OWNER'S NAM(J,(��' /'L/�1 C ^TYC1L�U�(,(y_LA117f�11Y'R91 / I r1 AN1N!�. ) ��Q �• <br /> ,CONTRACTOR I I YY�� L^{/ _-AIK)NPA ' �JT! /�! TACE �FHON[ <br /> BVR CONTRACTOR 1 A:MW N1 IKF --_1NON( <br /> TYPS Of SEPTIC WUPK NIW INATMlAMII L] %t►AIRIADC.PION❑ D"TRV.TION O <br /> IND SEPTIC BYRIIM 11RIA1111D rt 1 FUW M WI111b I VAIUBLF WITHIN 200 PILT OF SLIKL11Nfi I �►.0 TIaTNI I !IqW,AMM— <br /> INSTALLATION WIL"W4 PF%INNYP* ,`MlAt W.Al 0 U1111R❑ /' " /�__- --- —__^ <br /> NU MBa Of UVINO UMTS NUMBBI Of S&d100M5 NIMR A OF EA PLOYRS - <br /> CHAAALTEROFBOILTOABERNOF3FtFT. _My MUM"%011 CH PAC IfP WAIIN TAPIR <br /> SE►T1C TANKNOR[ASE TRpA[PI� iVPEAVIOCAPAf'IV —NO COLIPMTMl NiB��� <br /> PRO TRIATMLTIT RANT I$ 41TANC(TO N[AII 1 WELL t JF.^ FOUNDATION � ITORRTV LINE FOUNDATION 1y./� <br /> UFT <br /> PE <br /> PUMP <br /> UACIBNO UNE ❑�NO.S LENGTH OF U `NE& -�fJ J�B dAMSYSTEM <br /> NC(TO NIAW RT W L Z12$� PMOP(RTY UNIT <br /> RLTOR BED ❑WROTH LENGTH DEPTH TNBTANCETONIMOBT WELL FOUNOATION__PROP[R-YL'h( <br /> MOUNDED ❑MOTHLENGTH DEPTH tAC'ANCE TO NTAW BY:WELL FOl'NDATK)hPRDPERTY L'NE�_,�� <br /> IEEPAO[FITS PIH BILE_ NUMPER�INSTANCE TO NIAW PT.Wlll IOUNOATb)N��—PRUISRTV Ikt[1(/ <br /> H VLM ❑WA)TN Ll HOT H OE PIN DIST ANCE TO NCAA ST:WE LLQ—FOUNDATION FM-F RTY UNE © 1 <br /> DISPOSAL PONDS C3 MOTH._LENGTH_ DISH DISTAICE TO NEAREST,WELI FCUNDAIION rwlorERT•UNE tjl <br /> 010 <br /> 1 HEREBYCERTIFY THAT i HAVE PREPARE`THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE MTN SAN JOAQUIN COUNTY ORDINANCES AND STATE:AWS.AND FRAEII <br /> AND REGULATIONS OF THE SAN JOAOUM COUW Y.IORAE OWNCR OR LICENSED ADEN T'B W GNAI UR[CERTIFIES T HE FOLLOWING'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> TH18 PEAIAIT IS <br /> 5AIU. <br /> SHALL NOT EMPLOY ANY PERSOI.M SACH A MANNER AS 10 BECOME SUBJECT TO WORKMANSCOMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'SHIISNGOA <br /> CERTIFIfB THE FCLIOYNNG:'I CERTIFY THAT IN TME PERFORMANCE OF TH[WON(FOR WHICH THIS Pf WAIT IB ISSUED,I SMALL EM,ILOY PERSONS SUECT TO <br /> (,E=TM AMIICANT IAllil::All Sa IIOW IN/wVANC[FOR ALL RROUKIQItI,N{/F,EC^TION{ C/UMPIETE DRA RANO BELOW. <br /> Y SIGNED% C\JN _TITLE. )-Y l.lL�-/ DATE: ^ <br /> lv— 42 <br /> ✓✓�` PLOT PLAN DRAW TO SCAIEI SCALE '` <br /> 1.NAMES OF STFIIETB OR ROADS NEAREST TO OR IIOUI:OMO THE PROF4PTY, a.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOB[D <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS ANO NORrH DIP['TgNEXPANSION OF BIWAOI DISPOSAL"BTEMB. C. <br /> 3. DIMFNIIOWD OUTUNES AND LOCATION OF ALL E%)b"NG AND PROPOSED STRUCTURES. 6.LOCATION OF WELLS MTH!N RADIUS OF ONE M040MV 1.'IV FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.ANU WALKS. <br /> THE PFK)PfRTY OR ADJOINING PIIOPERTY. <br /> Kf <br /> IN <br /> .7-3,4 <br /> v� <br /> i <br /> PAYMENT <br /> RECEIVED <br /> MAR 1 1995 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISI N <br /> FOi DfIAiTMCNT USf ONLY �-/- AREA: � / <br /> //APPLICATION ACCEPTED PY_ Am/ W/!I -- UAI I <br /> JFAFI/„Il OR SVMPIN81KCTg`/N BV �% ./� —_,`)ATT FINAL INBISC'..SV�O A DATN� f-Ul-l� <br /> ADDITIONAL COMMENTS' <br /> ACCOUNTING 0 AID/ --IAC• — -_� ---- <br /> PC COO( 44 fI INFO AAW-41 PERI I TV C C /CASH RECEIVED■Y DAII M I PERMIT PLMSm INVOICE/ ^ <br />