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4, APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES [ <br /> ENVIRONMENTAL HEALTH DIVISION ` <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> ]EON-REFUNDARI F pERMIT EXPIRES 1 YEAR FRON DATE ISSUED <br /> (Com <br /> lete <br /> licatel <br />'LICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IANDUOIRINSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> IOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH 8ERV1GE8.ENVIHONMENTAL iIEAiTH DIVISION.APNI loS rj 9 Hw TS <br /> �y CITY LOT SIZE <br />+PER'S NAME IJ L..�G-Ir!rjs'S� A[>oRE68 �7 <br /> {�� �/�.� C A'�'�^ p, t �^7 /� a QPHONE_/} %"`l4(g p <br /> fTRACTOR�J` a.1/"Ivri�V• ���11tf3 �a3CiADDRESB ] 1' �1�Q1 yam . L1CI f �IS'1Iv] PHONE�"l` 'T"`� <br /> CONTRACTOR ADDRESS STS S7—['Z <br /> UCO PHONE <br /> E OF SEPTIC WORK; NEW FNSTALLAT�ON ❑ REPAWIBVADDNTION ^ <br /> SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE THIN 200 FEET OF SUILDINO.1 DESTRUCTION ❑ <br /> PARC TESi(R1 f 1 HOW MANY <br /> ALLATION WILL SERVE: RESIDENCE IR COMMERCIAL ❑ OTHER❑ AOOBoetlon# <br /> BER OF LIVING UNITS:_ NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: -&` . <br /> WCTER OF MIL TO A DEPTH OF 33 FEET; T. PTISUMP SOIL CHARACTER: P<J►7 WATER TABLE DEPTH �� t <br /> IC TANKIGREASE TRAP IKTYPWMFG L{�i `� CAPACITY NO.GOMPARTMENTB <br /> TREATMENT PLANT 11 INSTANCE TO NEAREaT: WELL FOUNDATION <br /> PROPERTY LINE <br /> TUFT STATION© SIZE TYPE OF PUMP t� SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br />*NG LINE 29 NO,s LENGTH OF TUNES � '~-{.D� DISTANCE TO NEAREST;WELL--13a0 T FOUNDATION (�o� <br /> ❑WIDTH —._F PROPERTY LINE too <br /> tam LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION <br /> PROPERTY LINE � <br /> IDED ❑1MDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION <br /> PROPERTY IRIS <br /> OE PITB ❑�e DEPTH �j 81ZE y NUMBER INSTANCE TO NEAREST:WELL FOUNDAMN B PROPERTY UNE <br /> N <br /> B -WIDTH 4. LENGTH ! L I DAH�41/ DISTANCE TO NEAREST:WELL d`FOUNDATION `F d <br /> FOUNDATT PROPERTY LINE I O M <br /> SAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.,WELL ION <br /> PROPERTY LINE <br /> BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> EGULATIONS OF T HE BAN JOAOU3N COUNTY.HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORWTBCH <br /> ERMIT IS ISSUED,1 SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br />)UTP <br /> AGTINO SIGNATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUB)ECT TO <br /> MAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 28 HOURS IN ADVANCE FOR^ILL REQUIRED INSPECTIONS. COMPETE DRAWING BELOW, <br /> Ix T"'LJ Iv_ Irl '1 •, TITLE: ► DATE.- <br /> PLOT <br /> ATE:POT PLAN TONIN TO SCALE)SCALEAPIA- <br /> AES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1, LOCATION OF HOUSE SEWAGE DISPOSM SYSTEM OR PROPOSED <br /> VNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DFBMBAL SYSTEMS. <br /> ENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS THIN RADIUS OF ONE HUNDRED FIFTY Fi.ON <br /> MING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS.AND WALKS. WI <br /> THE PROPERTY OR ADJOINING PROPERTY. <br /> ,-.-.,. <br /> ... . ; <br /> 4/&3. <br /> , o <br /> ..... tt .... . <br /> .... <br /> I. <br /> o .5 0 <br /> F . <br /> n. _ ......� .. .�. <br /> b.so. <br /> \ .. . <br /> 0 <br /> ...: �p <br />.,..... ... .,. .,. ..:,.., <br /> �I <br /> ... <br /> �!�O.IOL�.. ..... <br /> ho,v+�, RID... :.. ....... ......... .... .� ....... ..... . .. . <br /> to.6 .' ... :..... ...... . ....... ... ..: .. �= y76`... <br /> R DEPARTMENT USE ONLY ) �j <br />'iDk ACCEPTED BY DATE:-1 4 �+�'( �7 <br /> I �� ARE <br />'OR SUMP INSPECTION 8Y _ DATE_/C 7U /•' FINAL INSPECTION BY :21G DATE I 1 <br /> AL COMMENTS: <br /> A:8 <br /> INTING ONLY: AID# FAC# <br /> DE FEE INFO AMOUNT RE MI ITED C 1CASH RECEIVED BY DATE SR I PERMIT NUMBm INVOICE 8 <br /> o 3 � b� 2' Sfs� <br /> leatthServ. Em/iro.174(3196) s <br />