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APPLICATION FOR LIQUID WATF'A%XMIT <br /> SAN JOAQUIN COUNTY PUBL.I _,EALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i n P 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> i (209)468-3420 <br /> t <br /> NON-REFRN00.RLE PERMIT EXPIRES 1 YEAR FROM U0.TF ISSUED <br /> 1C@mpl@L@ in Triproutel <br /> APPLICATION IB HEREBY MADE TO THE BAN JOAUUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JDAGUM COUNTY DEVELOPMENT TITLES.cNAPrEn 0-111y100.3 AND THE <br /> �STJA�NDDARRD�/[@I OF BAN JOAOURJ COUNTY PUBLIC HEALTH GEEI/RNCES.ENVI NMENTAL HEALTH DIVISION. <br /> JOB A➢DFSESBfOR AP/Nf (1� [a ` e- ^-'T' - C� V` �LOT S,ITZE �t <br /> fl -2 <br /> �+.. OWNER'S NAME { ( � <br /> � � l RE <br /> y CY ADDSS caft�f i PHONE N ry U <br /> CONTRACTOR MTV V _ADDRESS 4 4 - �'`^'r"' LIC/ <br /> WB CONTRACTORADORER@ VCi FRIDNE <br /> TTPE OF SEPTIC WORK: NEW INSTALLATION R&AIRIADDITION❑ OFITRUCTION❑ <br /> INC SEPTIC SYSTEM PERMITTED IF PUBLIC SWKR IS AY IN <br /> LE WITISN 200 FEET OF BUILDING.] PMC TUTbI L 1 HOW MARY <br /> y�y(^J APwS.@nR. <br /> + INSTALLATION WILL S13JVE: (�610ENCE 1�COMMERCIAL❑ OTHER Q <br /> 1IISBBSR OF WINO UMTS:— NIANBIX QF BEDROOMS: NUMBER OF 6NPLOYFU: / A <br /> OF BOB,TO A DEPTH OF O FEET: CF�fY�7�8�UMP SOIL;CHARACTER. WATER TABLE DEPTH - <br /> { i C TAR SAFE TRAP ❑TMTO.Tra <br /> CAPACITY NO.COMPMTAIEM�6/�]/]J� <br /> ENT RANT❑ DI@TANCE TO Pm&mST: 4YEE.L t 0 J�! FOUNDATION '+ PROPERTY LME--I <br /> 1 r UFT STATION 17\�SIZE TME OFrPUUMP BAND OIL SEPARATOR IENCLOSED-Y-T— ( O4 I L <br /> LEACNG ONE Y.1'/NO.A LENGTH LINES U`� k �7. DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LEACHINGOF T' <br /> RLTER SED !❑WIDTH LENG7H DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH �ry LENGTH DEPTH DISTANCE TO NEAREST:WELL^T FOUNDATION PRGPERTY <br /> SEEPAGE PT@ ?/��p..,L�Ac&M YY-CZ t @RE ��tl E I NUMBER^DISTANCE TO NEARE@T:WEIL�_---DATION Y"W{�PROIERTY UNE I <br /> SUMPS `�LyJ WWT14 LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUIJDATgN PRDPERTY EINE <br /> DISPOSAL PONDS L]WIDTH LENGTH OEPTH DISTANCE TO NEAREST!WELL FOUNDATION Pm-- <br /> I HEREBY CERTrTY THAT r HAVE PREPARED THIS APPLICATION AND THAT TME WORK WILL B£PONE IN ACCORDANCE WITH B/Lfl JOAOUIN COUNTY ORDINANCES AND STATE LAWS'AND RULER <br /> A74o REDULATMOOTTIIE@ANJOAWMCOVHTY.HOME OWNER ORUCENBEO AGENT'*SIGNATURE:CFRrIMS THE FOLLOWING:'ICERfIFYTNATIN THE PERFORMANCE OFTHEY/ORK TORVM111CH <br /> t <br /> THIS PERMIT M t@@UEO,1 @H/!il NOT EMPLOY ANY PERSON fIR.N A MANNER AS TO BECOME WR1ECT TO VVOPKMAN7 COMPENSATION LAWS OF CAUFORSA.- CDHTMCTOR'B NINNO OR , <br /> BUpCOWMkCnM MATURE CERTWIES TRE POLLOVAM, CERTIFY THAT M THE IERFDRMANCE OF THE WORK FOR WHICH THIS PERiiIIT H ISSUED,t SHALL EMPLOY PERSONS(tVBJECT TO, ` <br /> WOIKMAN-S CO ION LAYYSr11NIA.' T ANT MUST CALL M HOURS W ADVANCE FOR ALL REQUIRED INSPECTIONS,COMPLETE DRAWING BELOW. <br /> 11M /s 2- <br /> SIGNED X TITLE W <br /> L <br /> O WTO 6'CAIEI SCALE In <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4,LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THT PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. <br /> EXPANSION OF SELVAGE PHI"DISPR LL I OF O B. <br /> 2.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E HUNDRED RFTY FT.ON <br /> INCLUDING COVERED AREA@ SLOCH AS PATIOS,DRVEWAYR,AND WALKS. Y <br /> S.LOCATION DF WL1.L8 MATMH <br /> THE RIOPERTY OR APJOIMNO PIIDP'ERTY <br /> 7771�� <br /> �4 . <br /> . <br /> ... .. .n. 4. <br /> (3�.... <br /> �. ¢.. <br /> t . <br /> d <br /> t_s 4 <br /> w <br /> -' FOR DEPARTMENT USE ONLY <br /> f DATF: G AREA:,APPLICATION ACCEPTED Bl' I /j <br /> DATE '!�U FINAL INSPECTION BY <br /> s9WK/�oR SUMP MSPECTIOIJ BY J ,/fT <br /> ADDITIONAL COMMENTS: SCC 'L 'r'�• i�� Y � lrO <br /> ACCOUNTING ONLY: NDi FACT - <br /> f F PE COOS FTE MPOAMOUNT RUA RED CIIEC /CASH REC9VED SY DATE <br /> E SR/P9tlJSToN MB6l INVOtCF I <br /> l <br /> Fi <br /> Pub.Health Sam-Enviro.174(3196) <br />