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APPLICP," ')FOR LI(IUiI)WASTE PERMIT <br /> SAN JOAQUI:,.,OUNTY PUBLIC HEALTH SERVICES t .� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> F HANAEFURBABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> (Csmplats In Triplicate; <br /> APPLICATION IB HEREBY MADE TO THE SAN JOAOLRN COUNTY FOR A PERMIT TO CONfTRUCT ANOIOR INSTALL THE WOFK DESCRIBED,TWO APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> F jDAWN COUNVE <br /> FY DELOPMENT TITLE CHAPTER&t T TO.B AND THE STANDAPD8 OF SA►/.NPUBLIC�lJOAOUIN COUNTY HEALTH CERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOAE581OR API/ I !� CITY - LOT BRE <br /> ER's NAME R`� RESB �I PHONE <br /> CONTRACTOR ADDRESS L/ LIC/�DNE �/JS.LL% <br /> Fj <br /> SVB CONTRACTORADDREGO TYPE OF ff P IC WORK: NEW INSTALLATION❑ REPNWAODITIONW DE mm-nON CI <br /> INO SEPTIC SYSTEM PERMr"m IF PUBLIC WMR IS AVAILABLE WITHIN 200 FEET OF BUILDINO.1 POW TEATI-1 1 I HOW MANY <br /> Appl-dal■ <br /> 'FINSTALLATION WILL SERVE RESIDENCE 7 COMMERCIAL❑ OTHER❑ 1 <br /> NUMBER OF WINO LIM NUMBEI OF�/a]]E/}&DOM �NR1Aa6l of RMPLOYEFJI: <br /> CHARACTER DF 60%TO A OEPrH OF 3 FEET: IY I U _PITFSUMP SOIL CHARACTER! WATER TABLE OEPTH -- -i <br /> SEPTIC TANKIOREASE TRAAP1 0 TYPE/MF G CAPACRY NO.COMPARTMENTS <br /> 1 PILO TREATMENT PLANTA DISTANCE TO NEAREST! WELL FOUNDATION PRDPEMY UHE ` <br /> N 1`�4Trs�TJA�7rON❑ mZE TYPE OF PUMP SAND OIL OIL GEPARATOR 1ENCLOSEO SYSTEMI <br /> �'tGCMN7 fJNIE'ron N0.A LENGTH OF LINES Il DISTANCE TO NEAREST.WE <br /> r1 r•+'r^�+^�^'^ fAIOPERTY LINE <br /> FILTER BW ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> FMOUNDED <br /> C�WIDTN LENGTH DEPTH IODISTANCE TO NEAREST:WELL FOUHDATN PROPERTY NN'SEWAGE PITS ❑DEPTH ORE NUMBER INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SUMPS Q WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DIs"SAI PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST!WELL FOLMDATIOH PROPERLY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APP ICATION AND THAT THE WOIR WILL BE DONE IN ACCOImANCE WITH FAN JOAO111N COUNTY ORIDIN—ED AND STATE LAWS.AND RULES � <br /> ANO AEOULATIONSOFTHE BAN JOAOLANCOUNTY.HOME OWNEROAUCENBED AGENT'S SIGNATURE CE WMSTHEFOLLGWHNS:'I CERTIFY THAT INTHE�EROa ..I.OF THEIYDRC FORWFRCH <br /> THIS PERMR is ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AO TO BECOME SUBJECTTO WOIRMAN'B COMPENSATION LAN@ OF CAWO7MA'CONTRACTOR'S HIRING OR <br /> _ BUR-.,NTMCT,N.SIGNATURE CERTIFIES THE FOLLOWING:9 CE9rWY THAT tN THE PERFORMANCE OF THE WOW FOR V*KH THIS PEM49 IS 188VED,I SHALL EMPLOY PERSONS SUNECT TO <br /> WOPKMAH'S_COMPENSATION LAWS OF CALNOPSII • THE APPLICANT MUST CALL M HOLM IN ADVANCE FOR ALL <br /> LLRE�OUREED IIN.SPEECTION&&,COMPLETEDMIMNG BELOW. <br /> mONEO% f 'TITLE. .l1s�s/•�Tirla DATE. — ~/ <br /> I <br /> PLOT PLAN(DRAW TO SCALE)SCALE--en Y. <br /> I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SLWAGE d6POSAl SYSTEM OA PROPOSED II <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> M8. <br /> DIMFNWONED OVTUNES AND LOCATION OF ALL EXISTING AMC)PROPOSED STRUCTURES, <br /> l 9 S.LOCATION OF WELLS WITHIN RAINUS OF ONE HUNDRED FIFTY FT.ON h <br /> INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WAIXS <br /> -.,............... <br /> ... u <br /> .:..0 ki.. .. (y <br /> x <br /> : ....I...- <br /> ..._. z <br /> � E .. . <br /> :... . .e ' . <br /> ..... <br /> - � t i <br /> �R,U <br /> .. ... <br /> ,. . ... .. .. ... . <br /> . . <br /> .. :... �: <br /> ..... xs�s7y.,,s x�-Q _ R CEI DI <br /> . . �"k <br /> DC,. 9kD <br /> ENViR� EryTAL iiEA1IHl]IVI 0ht <br /> ...` ... ... .-. L.,..t..... ..... .-... ...r. ...---.... <br /> F <br /> FOR DEPARTMENT USE ONLY ? <br /> APPLICATION ACCEPTED BY DATE: /2- ' r AREA Z <br /> �TANK,PIT OR SUMP LNSPEC 101 BY DATE I I _ FINAL INSPECTION BY DATE��!?' <br /> ADLNTIONAL COMMENTS: 1.^EI'2.060 1NFi'1 R,TR li•TOR 5 1 AJ <br /> - No ¢ DITI LI (D LAS jr <br /> Acc0...ONLY: AID/ FFG! <br /> PE/CODE FEE INFO AMOUNT REMIITEO CI{Tt: ABH RECEIVED BY DATEan <br /> ��'�Tr'-TT��� iR r PEWIIT HIIMSER <br /> 1�I o i'! V V , . <br /> i <br /> Pub.Health S.I.•Emim,174(3196) <br />