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APPLICATION FOR LIQUID WASTE PERMIT ~ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 <br /> (209) 468-3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complaw in Tripliiatal <br /> A ATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOPC DESCRIBED. THIS APPLJCATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVIR-OPMENT TTIIT'LEE.CJAPTER 9-1110.3 AND T ST'A'NDARDS OF SAN MAOUIN COUNTY PUBLIC HEALTH SER ES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR AAM.,�/ `^'(7/" __ RX XP/v*�l�-�<O/� CRY �n {/C�YN/a,�/ LOT 66E�4C{P <br /> OWNER'S NAMI5/I I TC/1P3 YQY� ADDRESS <br /> V�S I.L?I p./'C' �c RGe. PHONE 7 ys <br /> CONTMCTDg(yE�iSTAY/�ijG�At?i E(Y /NC AGDRE59/d BsX ��Jo -rhar L1C#6' 34/ PROD <br /> SUBCONTRACTOR ADDRESS lKA PHONE <br /> TYFE OF INWEIC WORK: NEW INSTALLATION n-ASU-04TION 13 MTRMEI.N ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)I I HOW MANY <br /> bWlwllon J <br /> INSTALLATION WILL E <br /> {ERN : RESIDENCE YlH/ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER GIF LIVING MT) NO UE NUMBER OF SEDROONVI: `)'J NUEEa91 OF EMP DYRa; <br /> CHARACTER Of SOIL TO A DEPTH OF]FEELS .1Dq PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> WWM <br /> SEPTIC TANIRE TP wTYPEAMFO CAPACITY /LDcby <br /> NO.COMPARTMENTS <br /> MG TREATMENT RANT❑ DISTANCE TO NEMFAT: WELL FOUNDATION NOPE ME <br /> LIFE STATION❑1{SjITE TYRE OF RUMP SAy0 OIL SEPARATOR(ENCLOSED SYSTEM) !- <br /> UEAI.RNO UNE n NO.i LENGTH OF LINES DISTANCE TO NEAREST:HEV.Roo TL FOVNDATroN�'�PRDPEFTY UNE `J D <br /> FILTER RED 13 WIDTH LENGTH, �LP�H a� DISTANCETONEAREST:WELL FOUNDATION mcmf T'LINE <br /> MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE .� <br /> SEEPAGE RTF 11 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> aUMPi ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY ME <br /> DISPOSAL PONDS ❑WROTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORN WILL BE DONE W ACCORDANCE WITH SM)JOAWIN COUNTY ORDINANCES AND STATE LAWS,AND RULL6 <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR MENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE MW FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT Y ANY PERSON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> 6UBLONTRACTI GNATURE CERT( IES TH FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUWECT TO <br /> WOPo(MAN'B MFEN DIT UW CALJ NIA.' THE PLICA UET CALL 21 FgtAi IN ADVANCE FOR ALL REOlA11E0 INSPECTIONS. COMPETE DRAWING BELOW. <br /> /] <br /> SIGNED XTRIF;�y(� to�� -1 <br /> DATE: <br /> ROT PAN 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 F <br /> 2. ODTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL WY M6. L <br /> 3, DIMENSIONED OUTUNES 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 PROPER OR ADJOINING PROPERTY. <br /> SkeD <br /> Lie// 7-Y&Iles- � <br /> ' oe <br /> tj <br /> 3—/dv' L/.vPS <br /> cTD�. <br /> PAYMENT <br /> RECEIVED <br /> MAR 2 1995 <br /> FIUBN,CO IF.ALT�COUNTY <br /> ENVIROiINIE [A.rjpj TN DIVISION <br /> r <br />