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z� <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> �F SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL <br /> SION <br /> P,O, BOX 988, 304 EAST WEBER AVENUEI <br /> S TOCKTON, CA Sc VI- 88 <br /> IQ. (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompAPPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT Io In I <br /> ANDMA INSTALL THE WOR(DESCRIBED. THIS APPl1CATION 18 MADE IN COMPLIANCE WITH BAN <br /> — JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110,3 AND THE STANDARDS OFF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREBSIOR APNI ^L T'T \`p Cm, �1Nt�lGt�1 Q�z� LOT SIZEL{-C <br /> OWNER'S NAME �.I kG�wSZw'�L,,.qG- ADDRESS <br /> CONTRACTOR lL .J EV\\l AODRE88 <br /> SUB CONTRACTOR ADDRESS )JCI PHONE <br /> S. TYPE OF SEPTIC WON(: NEW INSTALLAmN ❑ REPAINADDITION ❑ DESTRUCTION ❑ <br /> INC SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN ZOO FEET OF SUILDINGJ PSRC TUTOR 1 1 HOW MAN <br /> INSTALLATION <br /> APWIwMn i �l�-I <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UNITS: NINSM OF BE0110OMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF FOIL TO A DEPTH OF 3 FEET: W/BUMP SON CHARACTER: WATER TAME DEPTH <br /> SEPTIC TAWJOREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS <br /> PRO TREATMENT PANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> UFT STATION❑ SIZE TVPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH NG UNE ❑ NO.E LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> — FILTER DFD ❑WIDTH LENGTH DEPTH DISTANCE TO NEARER:WELLFOUNDATION PROPERTY UNE <br /> MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE RTS ❑DEFTH RAZE IS <br /> NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SUMPS ❑WROTH LENGTH DEPT" DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> S. DISPOSAL PONDS ❑WIDTH LENGTH DEPTH PRANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 1 HEREBY CERTIFY TNAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> AND REGULATIONS OF THE BAN MAGUIN COUNTY.HOME OWNERORLCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"CERTIFYTHAT INTHE PERP FMANCE OFTHEWORK MR"ICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWMCTOR'S MINNO OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WOWMAN' MPKENSATION LAWS OF CALIFORNIA.' THE AMUCANT MUST CALL 24 HOW IN ADVANCE FOR ALL REGUIRED INSPEC ION$. COMPLETE DRAWIN�GT BELOW. ♦� <br /> SIGNED% ❑�e . edit TITLE: <`a.ai1A wi M,_1 DATE: <br /> ROT PLAN(DRAW TO SCALEI SCALE 'm <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE R10PERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. E%PAHeION OF BEWAOE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WAL%8. THE PROPERTY OR ADJOINING PROPERTY. ' <br /> Yif 11 fe -i P' <br /> 3/y� -off z�Z1 <br /> � I <br /> d ��� JO /d /r✓ <br /> dUX 44 <br /> PAVfVfEN <br /> GiL cciclY �'' JUL 2 '0 1998 <br /> 1 3 d c4 ,d Cc vczc7�o « n <br /> W/ a /, COUNT,yP /j 1/F y zpuaucEPLTHSERVIIEFNRONMENJ n,E4uHDL(„tIn(. <br /> V�(S <br /> SCR <br /> FOR DEPARTMENT USE ONLY <br /> 7 /<J <br /> APPLICATION ACCEPTED By GATE: ` AREA: <br /> TANK,PIT OR BUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE <br /> ADDITIONAL COMMENTS: (! fgw'lwd�d <br /> -k1 dk1 l cl P <br /> ACCOUNTING ONLY: AUDI FACF <br /> PE CODE FEE INFO AMOUNT REMITTED CHEC AIM RECOVER■Y DATE SRI PFRMST NUMBER INVOICE I <br />