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�IICH FOR LIQUID WASTE PERMIT <br /> H SAI, iDU SUNTV PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX SM 304 EAST WEBER AVENUE,STOCMN,CA 9=1,W <br /> Fj <br /> {208}468.3420 <br /> ON-REFUNDAB PRM XP B S 1 yEAR FOUN DATESSU <br /> ARICemphl6 i6 Trokot&APPLICATION IB HER MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANpl)R INSTALL THE WOR(DESCRIBED THIS APPLICATION IB MADE rN COMPLIANCE WITH OAK <br /> JOAQUIN COUNTY DEVELOPMENT <br /> QTITLE,CHAPTER 9.1110. THE STAND OF SAN JOAQUIN COUNTY HIBLIC HEALTH SERVICES,ENVrR�HMENTAL HEALTH DIVISION, <br /> F.ADORE6610A APNO r I / O <br /> CN'Y LOT BtZE�fir, <br /> CONTA'S NAME -7 <br /> CONTRACTOR <br /> ADDRESS <br /> L COM LHG/�PHDNE-��� <br /> RACTOR I ADDRESS <br /> LICA PHONE <br /> rOE OF SEPTIC WORE: NEW INSTALLATION AtPAOUADDITION 13 DESTRUCTION❑ <br /> ANO SEPTIC BySTEM PERMITTED rF'PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUROINO.f <br /> ASRC 7FATdl f 11IGW MANY <br /> [IIALLAI"ON <br /> Apgb -P <br /> wru irJLVE; REBrDENeE� eoMMF�AL Q DINER 0'AREA OF OF UVINO UNITA: NuRMER OF BEDROOMS: NUM691 OF EMPLOYm: y� <br /> CHARACTER OF 504 7O A DEPTH OF 7 FEET: FITISUMP�1L CHARACTER WATER TABLED L/ <br /> F09,Me TANIUOREASE TRAP ❑TYPE&wa CAPACITY_ � NO.COMPARTMENTS <br /> ,' REATMENT PLANT❑ DIBTAMCE TO NEAREST: WELL_ �Zb FOURDATION PROPERTY LINE <br /> UFT STATION❑ 81 TYPE OF PUMP BAND OIL SEPARATOR WNCLOSED SYSTEMA <br /> LEACHtNO LINE NO.r LENGTH OF LINES_ DIOTANCETO NEAREST:WELL DNDATION PROPERTY LINE�� <br /> FILTER BED i O WIDTH LEHGTII DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> IINDED []WIPTII`t LENGTHr DEPTH DISTANCE TO NEAREST:WELT. FOUNDATION/' PROPERTY LINE <br /> ATS 0 DEPTH Sm NUMBER.�+ _WSTANCE TO NEAREST:WEL.i,�OUNDA7pN pgppEPrry <br /> twlM O WrPTH LEMOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PAopEHTy LINE <br /> DISPOSAL PONDS 0%MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY L1NE <br /> f"Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE BONE NP ACCORDANCE WITH BAN JOAQUIN COUNTY ORDIIANCES ANO STATE LAWS,AND RULES <br /> )REGULATION OF THE SAN JOAOUIN COUNTY.HOMI:OWNER ORLIOEHSFD AOENT'8 SgNATURE CERTIFIEB THE FOLLOWINO:9 CERTIFY THAT INTHE PERFORMANCE OF THE WORK FOR WHICH <br /> .B PERMIT 18ISSUEO,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WDRLMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'&RARING OR <br /> SUBLONTRACTING MHATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMfT IS IBBUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENIATON LAWS OF CALIPpRMFA.' THE APPLICANT MUST CALL b H OW0 IN ADVANCE FOR ALL REQUIRED INAPECTIONS. COMPLETE DMWWq BELOW, <br /> FNED, <br /> TITLE! DATE: <br /> MOT PLM(DRAW TO SCALEI SCALE <br /> 1.NAMES OF STREETS OR ROADS NEAREST to OR SOUNOING THE PROPERTY, S. LOCATION OF HOUSE SEWAGE DI&PORAL SYSTEM OR PROP'OSED <br /> IRLrNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTAIN, EXPANSION OF SEWAGE DISPOSAL,SYSTEMS. <br /> DIMENSIONED OUTLINES AND LOCATION OF ALL EXIBnno AND PROPOSED BTRUCTUREe, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,OR <br /> VCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK8. THE PROPERTY OR AQIOININQ PIgpERTy. <br /> ... f.. l ... .... .. .. . .. _ .._ <br /> . I <br /> .., .._. .... - <br /> :: <br /> 1 <br /> 7-1 <br /> _ � I <br /> ¢........ ................................ <br /> FOR DrPARTMFNT USE ONLY _ <br /> f`11CATH).ACCEPTED BY <br /> GATE: AREA: <br /> �rnyic,&6.,SUMP...IPECTIOII BY DATE/�,��`IFINAL INSPECTION BY <br /> FIONAL COMMENTS: <br /> i <br /> LACCOT/NTINO ONLY:' AIDS - FAGP <br /> PE COOS FEE INFO AMOUNT RE ITTm CNBC TCAiN RECENFD B)' DATE SRlP6tLGT NUmBEI PRVOICEP <br /> I <br />