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APPLICATION FOR LIDUID WASTE PERMIT <br /> SAN JOABUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 980,904 EAST WEBER AVENUE STOCKTON,CA 95201500 <br /> _ (209)4883420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUER <br /> ICORPI{N IS TrVU{{bl <br /> AFFMATION IS HEREBY MADE TO THE BAN MAOUW COUNTY FOR A PERMR TO CONSTRUCT ANOMR WBTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WYFH BAN <br /> JOAQUIN COUNTY DEVELOPMENT/IDLE],C'HlA'PTERR 8-111100..0 ANDTHE <br /> STANDARDS OF RAN JOAQUIN C�O(I//N�T�Y PUBLIC HEALTH SERVICER,ENNPONMEMAL HEALTH OINBMN. <br /> ` JOB ADDRESSAM.1 d,Qao` l__ 1..1111P -Frep `(ti\ CITY _ � !11 )V ]LOOT�NZF LV4(rl <br /> OWNER'RNAME l,y)(11'% 1l. JIMQYIPz A00PEB8 l ba / I��YYAV, TCY✓\ A�., RHINE JO-y! <br /> COHTMCTOR AppPESB LICE RIONE <br /> BUB CONTRACTOR ADDRESS VLE MME <br /> TYPE OF{EYRIE WORI[: N[W IM{TIWTON NEPAWAOWTION ❑ BFlT11VCT10M 13 <br /> INO SEPTIC SYSTEM PERMITTED IF MOM SEWER IB AVMUBIE WRHIN 800 FEET OF BUIMINO.1 FEW TEBTISI I I HOW MANY <br /> _ APFS—Mn E <br /> IN{TAUATIOX W U-MOVE: RENDENCEX COMMEIICIAL❑ OTHER❑ <br /> HIAA{fA OF 1MN0 YMT{: NIM8D1 OF BEDflOOMt: NUM891 OF BAPEDYEY:� <br /> CHARACTER of 80R TO A DEPTH OF 3 PPT: /BUSY 901L CHARACTER: WATER TAffiE DEPTH <br /> SEPTIC TAN%/OIIEAGE TRAP TVIFAIFO VAL!/` CAPAan� COMPARTMENTS <br /> P%O TREATMENT PLANT 11 DISTANCE TO NEARENT: WELL FOUNDATION PROPERTY,LINE <br /> LFT tTATON 11 RATE TYPE OF J J BAND OIL SEPARATOR IEHCLOBEO BYBTEMI�''pT <br /> NO / <br /> LEACNNO UNE .i MOTH OF OWER JDURANICE TO NEAREST:W2LL ''p��FOUNDATION k5 ¢PIORENTY ME <br /> FILTER[Ep ❑WOOTN IEWH .1. DISTANCE TO NEAREST:WFll FOUNDATION PROPERTY UNE p <br /> ISSS MOOxOFp ❑WIDTH IENOTH DEPTH DISTANCE TO NEAREST:WELL WUNOATION ROPEARY ME <br /> tEVW[RTS 11 DEPTH RII-�NVMBEn DISTANCE TO NEAREST: <br /> NIMH y,,q-A WEFOUNOATON POFTYUHE <br /> WOT1� pBTNEONEA1E8fW773_VFOU.ATI0N NRRry UNE 1v` <br /> O <br /> WGFOML PoNOt ❑W'1I IFNOTN DEPTH ONTAHCE TO NEAREST:WELL FOUNDATION PFOPERN USE <br /> [KK I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPMATOH AND THAT THE W OM WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY O WINAHCEB AND STATE LAWS,AND WIEB f <br /> AND REGULATIONS OF THE BAN JOAW W COUNTY.HOME OWNER OR METHOD AGENT'S SIGNATURE CERTIFIES THE FDLLOWTNO:'I CEIRTIPYTHAT IN THE PERFORMANCE OF THE WORK FORYMICH <br /> THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY ANY WHICH W NCN A NA MER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE MU-OWINO:'I CERTIFY THAT IN THE RRFONMANLE OF THE WOW MR NMICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'8 COMPENSATION IAWS OF CALIMM THE ARUCYIT MUST CALL Bi M UNIS IN ADVANCE MR ALL MQUIREO IN{FKTIONS. CONRETE DRAWING BELOW. <br /> SIBS <br /> BOHEO% LLLtNECI_ ©= TITLE: IY [,E�`%tel P lC..��t��DATE: / <br /> ROT N IOMW TO SCALER BCAIE '1 le <br /> 1.NAMES OF STREETS OR WADS NEAREST TO OR BOUNCING THE MISINFORM i.LOCATION OF HOUSE SEWAGE OIEPoML SYSTEM OR P OPOSED <br /> 8.OV VNE OF THE PROPERTY.WITH DRAENSONB AND NORM DIRECTOR. EXPANSON OF SEWAGE OISOBAL SYSTEMS. <br /> DIMENSONED OVTUNES AND LOCATION OF ALL EXISTING AHO PROMISED 6TRUCTUREB, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS DRYFW'AYB,AND WALKS, THE PPoRRTY OR ADJOINING PROPERTY. <br /> E-_ <br /> RICWOIXOLOVEREO AREA86UCH AB PATIOS pRVEWAYB,AND WAIJ(e. THE PROPERTYOPAO.IOIN 'aryoRnl <br /> 1 <br /> _ <br /> � s w <br /> �I[ <br /> s <br /> bo <br /> I� <br /> �LG7�5 /y1 <br /> , I <br /> lkl� <br /> FON ORMTMBFIT WEONLYOP�A YOO" �� 'Ql <br /> APPLICATION ACCEPTED BY ,/I/!I"/'!/ DATE: ''V� AREA <br /> TANK.FIT -4 ? <br /> T OR SUMP INSPECTION Sv GATE l I FINAL 6CTION DATE <br /> ADDITIONAL COMMENTS: C <br /> FS <br /> P, IVY- <br /> ACCOVNTNO OXLY: AIOI FACT <br /> PE C00E FEIRM ANOONTNOWTTED HEC MA6N RECDVFDBY GATE N/PDNIIT NVAB[R INVOICE• <br /> yal/ <br /> II � ' <br />