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APPLICATION FOR LIHID WASTE PERMIT <br /> SAN JOAQ;'—"r.=NTY PUBLIC HEALTH SERVICES <br /> ENE. ,NMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICBmp1EtE IR Trtpl'HAtII <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT AND10INSTALL THE WORK DECCRBEM THIS APPLICATION IS MADE M COMPLIANCE WITH BAN <br /> io"m COUNTY DEVELOPMENT TITLE CHAPTER 2-1110.3 AND THE STANDAIIDB of SAN JOADVIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADMISSION APNI /� Q�} 1 CITY - LOT SIZE <br /> .OWNER'S NAME Y� I�JL /i �(_L f REBS PLIGHT <br /> _ ♦ � �� /^����Jy�� <br /> CONTRACTOR. yLR�=,L"'("'-' ADDRESS_ f� <br /> 41 SUB CONTRACTOR ADDRESS LIC* ALONE <br /> FTYPE OF SEPTIC WORK: NEW INSTALLATION[3REPAWAt)MnDNW DESTRUCTION 0 <br /> �yi.RNO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 2GO FEET OF BURDINGO I+BtC TESTIII t)NOW MANY <br /> ' APT41nSPn/ <br /> INSTALLATION WILL SERVE m <br /> 1¢ OFNCE yF COMMERCIAL❑ OTHER <br /> NUMBER ❑ <br /> ]`1}� <br /> NUMBER OF LIVING UmrLil: NU/�A BER OF�SI FJ�IJW�OiNS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF WtL TOA DEPTH OF]FEET: H"V PTTISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANITJOREASE TRAP QTYPEMFO '- CAPACITY NO.COMPARTMENTS <br /> I <br /> 1 PK07RFATMENt RANT❑ DISTANCE TO NEAREST: WELL FOVNOAT1oN PLOPITNTYUNE <br /> UFT STATION❑ SIZE TYPE OF ATMP $$A�NNDD OIL SEPARATOR iENCLOSED SYSTEM) � _ <br /> LEACMMA TINE'��� HO.A LENGTH Of LINES / OIBFANCE TO NEAREST:WELL„�f!/!! F011NOATION�j�PROPERTPROPERTY �� <br /> TTY LINE e/C.J / <br /> FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL POUNDAT'ION PROPERTY LINE <br /> MOUNDED ISI WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> rSEWAGE PITS 12EPTH OS= NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SLSUAFt ❑WIDTH LERGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE to NEARER:WELL FOUNDATION PROPERTY LIME <br /> 1 HEREBY CERTIFY THAT I NAVE PEPARM TMS APPLICATION AND THAT.THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE)AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE$AN JOAOUIN COUNTY."DME OWNED DRLICENBED AGENT'S SIGNATURE CERTIRES THE FOLLOWING:-ICERTIFYTHAT I{THE>ERFD MANCE OF THE WORK FOR WHICH <br /> THIS PMATT IS MBUED,1 SHALL NOT EMPLOY ANY PERBON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOPRMAMS COMPENSATION LAWS OF CAUPGRMA.*CONTRACTOR'S HIRING OR <br /> SUB-COHTMC —SIGNATURE CERTIFIES THE FOLLMMNG:'I CERTIFY CHAT IN THE PERFORMANCE OF THE WOPR FOR WHICH TMB PER.ttT M ISOM,1 MAL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORM • THE APPLICANT MUST CALL 24 HOURI IN ADVANCE FOR ALL REOMM INSPECTIONS.COMPLrTE DRAWING 1111.17W. - <br /> k i <br /> SIGNED% f <br /> k <br /> i <br /> RAT RMI{DRAW TO SCALET SCALE •b <br /> NAMES OF SMEET6 OR ROADS NEATEST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HSAL OUSE BFWAOF DISPOSYSTEM OR PROPOSER <br /> -F., <br /> .O <br /> UTUNF OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIAM71oH. EXPANSION NOF SEWAGE DISPOSAL SYSTEMS. `.. <br /> w D.DIMENSIONED OUTLINES AND LOCATION OF ALL MIMING AND PROPOSED 6TRUCTUEG, 6.LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT.ON (�] <br /> INCLUDINo COVERED.REAS MUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR A=INING PROPERTY. <br /> ._ .. _ <br /> .......... ........ <br /> .Z <br /> � N „ <br /> N „ <br /> ..., ...... <br /> fit <br /> .. ......... ............................ .... ............. <br /> ....... ............ s .... t.... `` ' <br /> �,,�,.G.....;..,,.;,... { <br /> c; . ... <br /> ...:. <br /> ....... <br /> ..... .... ......... .............................. <br /> ..... <br /> E N- <br /> 17' <br /> �� R <br /> ...., <br /> VED <br /> ...-..n <br /> . EC D .ZOO. <br /> - ...... . ... <br /> . r sar7 ioaouiti cauid r <br /> f!'V � HEALTH SERC+�CES ... <br /> ...... ...... ....:. ............, : . ..... <br /> ENR.)BEN C�Fri IA E FiEA.l I H.II1V1510 N <br /> ....... <br /> ...... <br /> ............. <br /> .. .� .. i1... ...... .......... <br /> ...... ................................. <br /> ...... ...... ........... <br /> .... <br /> ....... <br /> FOR DEPARTMENT USE ONLY /) 7/��/''�'•� <br /> APPLICATION ACCFPFED BY---LYV DATE: ` 2' <br /> TANK,PIT OR HUMP INSPEC IDI BY �DATE I I FINAL INSPECTION BY OATS 1Z 12l(2a� <br /> ADWTIGNAL COMMENTS: ju-LI-Z.B�O INE•,I..1.+�}f� �J f� <br /> e E RIU d <br /> ACC oxLr: AUDI FAc* <br /> I <br /> FR CODE FIE INPO AMOUNT REM)ITER CHEC ASH RECEIVED BY DATE SII T RMI"NLMSHI�.. INVOICE <br /> 'v-Z/o L.6 L <br /> Pub.Heats Serv..&Mro.174(3!96) R <br /> r <br />