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� ra <br /> ` APPLICATION FOR LIOUIO WASTE PERMIT �0v <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, 904 EAST WEBER AVENUE, STOCKTON, CA 9x201.388 <br /> (209) 409.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> mplets In <br /> APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTIRUCT ANOMRINSTALL THE WORK DESCRIDEM THIS APRKATION IS MADE M COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COVHTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> Joa ADDRESSMA AM, / 5 0 0 LJ Ll i �r,� D� // -- nn ' <br /> OWNER'S NAME �S / O PVA ADOM89_7 S(J I W K I� I�r.�' pCOd( , pEry X 10 S d <br /> CONTRACTOR f"r t �AA'I'1 �/gcljtY vrI �AA;ADOMSS 7/ V 130k 3 LICIS 9/G 361PRONE-25S Z/72 <br /> BUB CONTRACTOR ADDRESS (2"q- 9 s-s v6 DC 6414- vu � <br /> IC/ "W <br /> TYPE OF SEPTIC WOR: NEW INSTALLATION REPAIR/ADDITION ❑ DESTAIICTION ❑ <br /> PRO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING! 7ZPPII�d.� <br /> ST(FI 1 MOW MANY <br /> - <br /> INSTALLATION �j / �A G <br /> INSTALLATION WILL SFAVE. RESIDENCE❑ COMMERCIAL ❑ OTHER `/UtT� / E55.-5 '�Or.�/ T' y� Q <br /> NUMSER OF LIVING UMTS: NUMBER Of SED/1ROOMB: NUMBER OF EMROYEES: J s"r/LGI P ~� J <br /> CHARACTFR OF SOIL TOA DEPTH OF 3 FEET. BAKE J�X -i HUMP SOIL CHARAC7 WATER TABLE DEPTH <br /> SEPTIC TANIUGNEASE TMP f z.TYPEWFG_ EX* Z L 4�1 I_v-rAod" /6 O _� NO.COMPARTMENTS L <br /> FAO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL /2 Q T FOUNDATION /O f PROPERTY UNE pOr t <br /> UFT STATION❑ SIZE TYPE OF PUMP ^ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> L"CHNO LIME ❑ NO.•LENGTH OF MIB_-2- (29) / -!S"' C'` DISTANCE TO NEAREST:WELL FOUNDATNIN. PROPERTY UNE­ZDO I7�- <br /> FILTER BED ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME <br /> SEEPAGE PTS ❑DEPTN SI[E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUM" ❑WIDTHS_LENGTH DFPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> dery SAL FONDS ❑WIDTH ?P LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME <br /> I HEREBY CERTIFY THAT 1 NAVE PREPARED TRIS APPJCATION AND THAT THE WOR(WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES ANO STATE LAWD.AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S WONATUM CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMKO PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWRACTOR'S HIRING OR <br /> SVS-CONTRACTING SIGNATURE CEATIRE THE FOLL NO: 'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WOWMAN�KN� OF LIFORNIA.' NEAPPU' MTM CA4 34 HOUg61N ADVANCE FORT ALL REOURED INSPFCTOMS. COMPLETE DRAWING BELOWSIGNED%(/ TITLE. DATE: <br /> ROT RAN(DRAW TO SCAM SCALE <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROFOBEO <br /> 3. OUTME OF THE POPERry,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE NOPOSAL SYSTEMS, <br /> 3. DI HMNEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 9TROCTUREB, B. LOCATION OF WELLS WRTHIN RADIUS OF ONE HUNDRED FlFTY FI.ON <br /> INCLUDING COVERED AREAS SUCH AS PATro9.DRIVEWAYS,AND WALKS <br /> . <br /> THE PROPERTY OR ADJOINING PROPERTY. <br /> �OYaV / GV„De� i <br /> > 'r 7 <br /> P� <br /> - �KAr�lh✓ / 1 ti I`p <br /> _�7 e <br /> --Too 13LJ <br /> �pk <br /> `ro�IRdtyMEN QRZtHSEAIn,.. <br />