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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ra BOX 3Et8,304 FAST WESER AVENUE,STOCKTON,CA 95201388 <br /> (209)4633420 <br /> ON-REFUNDABLE►ERN4T EXPIRES 1 YEAR FNOr DATE ISSUED <br /> (Glylw In Tr*NuW <br /> APPLICATION IS h•NEEY MAGE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO COW AUCT ANDOOR*MALL THE WORK DEOCRBED. TWO APPLICATION IS MADE N COMPRiANCE WITH MN <br /> AAOUIN COUNTY LIEVE'IA"V T TITLE.CHAPTER 9-1110.3 AND <br /> �TRE STANDARDS OF MAN7JOAOUN COUNTRY PUBLIC HEALTH Of11VICE6,ENVNDNMENTAL EtAL.TN OVISH'JM <br /> JOSADDRE9wF,AP-,_516_0/SQ E. 0odd4r!.S,K.l,4U ry�O/!/-�U�.7o-��_3 c `/ ACA. <br /> -,oo --LOT fIZ([T] <br /> ITMER'S NAME! R-T' Y(loNDAJI �A�-,-C_,7�T ADDRESS I•Q. IAL `G�sV L4JO �r.Q'CC/C� /J G�URpNE l3�/'�01'�l <br /> CONrMCTOR OW N e�ADDRESS S#Vne- UCF _PHONE <br /> SUS CONTRACTOR ADOIEOS UC/ PHONE <br /> TYPE Of SEPTIC YVORK: mrw INSTALLATION❑ RrAMADDITION CI DOOTRUCTIoN 14, <br /> M SEPTIC SYSTEM PENMrrED IF PUBLIC SEWER 16 AVAILABLE WITNN IDO FEET DF SUILOINO.I PEIC TMTU0,I 1 NOLV MANY <br /> ASPN-NN`S <br /> NISTALLATION WILL SMMR PEEDENCE L COMMERCIALIt OTHER❑ <br /> NUAOMR OF UVRNO USrS: NL*ASOR,W NEDNOOMG: NLM1111 Of EAPLOVIM: <br /> CHARACTER OF SOB-TO A DEPTH OF 3 FEET: P"MIUMP SON CHARACTER: WATEIR TABLE DOTH <br /> &OTIC TANKRVEA&S TNAP ❑TVPEMFO CAPACITY NO.COMPARTMENTS G <br /> ►KO TIEMN <br /> ATMT PLAT 11 OGTANCB TO NI/ARIIOT: HELL FOUNOATION PmrERrY LINE v <br /> LIFT STATION❑ SIZE TYPE OF PUAp BAND OIL SEPARATOR(ENCLOSED SYSTEM( `' 1 <br /> LSACNNO LPN C7 NO.*LENOTHI of LINES^ DISTANCE TO NIAIEIT:V/ILL FOU DATION PROPERTY UNE <br /> FILTER ISD ❑WIDTH LENGTH`_DOTH DISTANCE TO NEAREST!WELL _►OVNDATON PROPERTY LSE <br /> AOKNDFD ❑WIDTH LEMOIN __ <br /> ODYN OISTA14CE TO NEAREST:YYELL--_fOR.SOATIOIYFROYS <br /> M"LA <br /> SOS R <br /> AOTS 11DEPTH KIE ANRMRER DISTANCE TO NEAREST:VELLFOUNDATION RIOPORY LONE <br /> SUMPS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:Y/ELL`-FOULDATION PROPERTY LITE Q� <br /> OSm4AL PONOS ❑worm 1ENOTH OA'PTH DISTANCE TO NEAREST:WELL_ FOUNDATION P OPIERTY LIE Wx <br /> I HEREBY CERTEY THAT 1 HAVE PREPARED THIS AAt1CATION AND TWAT THY WOR(WRL BC DOFF N ACCOFOANCE`NTN SAN JDAOUN COUNTY OPE NIANCES AND*TATE LAWRI,ALO'M"'U�LES <br /> OUL �Y� <br /> AND PEATIONS OFTHE SAN JOAQUN COUIfTY.HOME OWN" LICENSED SIONATUFIFCERTEES THE FOLLOWED:ICVMIFVTHAT NT/LE PERFORMANCE OF THE WORK FOIL V <br /> TIOPE <br /> N RMIT IS ISSUED,I SHALL HOT EMPLOY AHY PERSON N HEP SUCH A MAAS TO BECOME SUBJECT TO WOPAMAN'S COMPENSATION LAWS Of CALMDRAA." CONTRACTOR'S H"w_OR((('') <br /> RUB-CONTRACTING SONATUIE CERTIFIES THE FOLLOYWOM:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WU!SC FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PRISONS SUS.IECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APP ICANT MUST CALL 34 HOURS N ADVANC■11.ALL ®IMNPREDNI. COAMLETF"..BELOW. <br /> FIONED K TITLE:/ '-'� � 1�1' DATE: 9 7 <br /> PLOT RAN!DRAW TO SCALD SCAIEr-_S_'m <br /> 1.NAPES OF STREETS OR ROADS NEAREST TO OR BOU OINO THE PA DrFr TV. A. LOCATION Of 1HOUPE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTUNF OF THE PROPERTY,WITH OtMENKONS AND NORTH DNECTION. OKPANSM OF SEWAGE DIWOaAL SYSTEM. <br /> 3. OIMEHSONEO OVTUNES AND LOCATION OF ALL EXWt*M AND PRROPOOED OTIOICTULE/, S.LOCATION OF WELLN WTHMR RADOM OF ONE HUNDRED FIFTY FT.ON <br /> WLUDNNO COVETED AREAS*UCH A*PATIOS,DRIVEWAYS,AND WAUM THE PROPERTY OR ADJOBSNG IFIDPERTY. <br /> 2 pea:4.jr. <br /> azo' <br /> v <br /> Scn�e <br /> - u <br /> PA''YMENT . ... ... <br /> 3 ? RMEIVED 5..... <br /> _. .. AUG <br /> c1 Fred p1ay►► a. _: . <br /> F-I�I <br /> SW JOAOU W COUM1EY <br /> Pl/&1C HEALTH SETiV."3 <br /> ENVIRONMENTAL HEALTFEDrovAm <br /> :.... ... <br /> • I <br /> FOR DEPARTMENT RISE ONLY <br /> APPLICATION ACCEPT'D BY /V&'' DATER _ J" <br /> TANK,PR OR OLAP%INSPECTION BY DATE 1 I FINAL NPE <br /> MCTION W G"JDATEyy/••_-Yt1 lI 7/ <br /> AOOITONAL COMMENTS. <br /> ACCO'UNTNO ONLY: AIDE FACT <br /> FE CODE FSE INFO AMOUNT MOTTM CHK;)/CASH RECOVm MY DATE M/PERMIT NUNNOR wvmK F <br /> a 1 12-7s s 6 -k 7z <br /> s� <br />