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a APPLICATION FOR LIQUID WASTE PERMIT <br /> 3;,+23 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> L. 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complet!in TFpliUtal <br /> APPLICATION 18 HEREBY MADE TO THE BAN JOADAN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAWIN COUNTY DEVELOPMENT TITLE CHAPTER 9.1110.9 AND THE STANDARDS OF BIW JOAMIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESIVORAFN/ 7633 C. F-emen l4^1 rT A. /, CRY .�Gi�/ e�C Lt11 LOO-]TT SIZE <br /> -I T <br /> A� OWNER'S NAME 1T'�'V�I" ''V/ ✓\jj W. /V�Y1 L✓ ADDRESS 76, 33 /1�-F�'T.✓LFI C ��1� .(. PHONE_/O y - /7 73 <br /> CONTRACTOR �/Qa,N /'(1 1V III ADDRESS 3 2.7 L/ F i� ✓��I1C/ Y,;t 2 4 PMNE 2`/G ' -? <br /> WS CONTRACTOR ADDRESS UC/ RHONE <br /> TYPE Of SEPNC WORK: NEW INSTALLATION Cl REPAIRIAUDIT1ON DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF RIBUC SEWER I6 AVAILABLE WITHIN 200 FEET OF BNILERM) PERC TRSTDI I I HOW MANY <br /> ApPNaatlen/ <br /> INSTALLATION WILL SERVE' RESIDENCE COMMERCIAL ❑ OTHER❑ <br /> NUMBER OF WINO HATS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> CHARACTER OF 600.TO A DEPTH OF 3 FEET: PITMUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPRC TANW E TMP ❑TYTIMIM CAPACITY NO.COMPARTMENTS <br /> r <br /> OKD TREATMENT RANT❑ DISTANCE TO NFARFEi: WILL FOUNDATION PROPERTY UNE <br /> IIFT STATION 0�S(/ZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> LEACHING UNE x NO.S LENGTH OF MEG / - Ice) F/ TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> FILTER BED ❑mm" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WAOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PIOPERTY UNE <br /> SEEPAGE RTA 11 DEPTH iXZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> awn ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL__FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDB ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATION FROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE W M WILL BE DONE IN ACCORDANCE WRIH SAN JOAWIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND WOULATIONS OF THE SAN"AMIN COUNTY.HOME OWNER ORMENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH <br /> — THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIMANIA.• CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE MI LOVANG:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WIOIKMAN'B COMPENSATION WS OF CALIFORNIA.- THE APPLICANT MUST CALL N/DURA IN ADVANCE MR ALL REQUIRE(D'�INSPEDR <br /> CTIONS. COMPLETE AWING BELOW. G, <br /> _ SIGNED X E'" V H� V TITLE: Je/ ¢I/ ✓� d ei'V o aJ( DATE: /!HJ-S / 7 <br /> ROT PLAN IDRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WATH DIMENSIONS AND NOUN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, <br /> � I.• 7 vew �.yyr c � c <br /> TIC �jo' n , <br /> T. e <br /> OCT 8 <br /> oUDUO HCAUH SEpV{CES <br /> FookONfAENTALi HEALTH DIVISION <br />