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APPLICATION FOR LIOUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201588 <br /> (209) 4883420 40 ` a P"T <br /> ( 1 ' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ICPmpIBte in TriplieStal <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE MTN SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER <br /> w9-1111 X19.3 AND TIRE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SER ES,EN.IRON{Mf/FNTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR AM4­1 /]V�T//�" CITY. / L1�- LOT SIZE <br /> �_ <br /> OWNER'S NAME ADDRESS PHONE :V <br /> / EF /� � X .fJ <br /> CONTRACTOR - ADORES6 LTCB 7 PHONE W( <br /> SUBCONTRACTOR AODRES6 UCB PHONE <br /> TYPE OF REYIIC WORK: NEW INSTALLATION ❑ REPAIMADDITION DESTRNCMN ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILDINGA PERM TESTNI 1 I HOW MANY <br /> pp APWleatlon <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF WING UNITS:_ NUMBER OF BEDROOM{: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> 6EFMC TANK/GREASE TRAP ❑TYFE/MFO CAPACT' NO.COMPARTMENTS <br /> PRO TREATMENT PLANT ❑ DISTANCE TO NEME6T: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP nSAND OIL SEPARATOR(ENCLOSED SYSTEMI ''// S <br /> LEACHING UNE ❑ NO.S LENGTH OF ONES �CJ t DISTANCE TO NEAREST:WELL FOUNDATION��PROPERTY UNE 'T Q! <br /> FILTER BED ❑WIDTH LENGTH DERH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE _ <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL �I///���ggqI FOUNDATION PROPERTY UNEP_ <br /> SEEPAGE PT ❑DEPTH `SIZE R NUMBEDISTANCE TO NEAREST:WELL O{/ FOUNDATION PROPERTY LINE <br /> SUM" ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE CAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH L._ <br /> THIS KAMM IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WOP(MAN'S COMPENSATION LAWS OF CALIFORNIA: THE APPLICANT MUST CALL 24 NOW IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPETE DRAWING BELOW. F� <br /> SIGNED%_ CL ,l->� TME: l _L'y) DATE: <br /> 1 <br /> PLOT MN(DRAW TO SCALE(SCALE 'to <br /> 1. NAMES OF STREETS OR(WADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTE OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS W THIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> E -j ---- <br /> -A�I <br /> Z � <br /> AY ENT <br /> v <br /> b RECEIVED <br /> NeK' <br /> AUG 12 '1997 <br /> SAN JCAULJjN <br /> UBLJC HEALTH S1,,n,-- <br />