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APPLICATION FOR LIOUIU WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Meanpl/t/M TripRnul <br /> APPLICATION IB HMERY MADE TO THE BAN JOACUIN COUNTY FOR A RREAIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. TMB APRJCAMmm IS MADE IN COMPLIANCE WITH SAN <br /> JDAONN COUNTY DFVFLORA <br /> TrItTUE.C / 1R 8-11110.3'A`NDTHEEB.A". AOS O% // COUNTY MOM HEALTH <br /> 9/E)ILIIVV/LICES MAL HEALTH UNHOOK <br /> JOB MDSDRANIW / ACRY � LOT <br /> �RIZE YG(�!o 1U <br /> OWMER'Sfmkhl Y /2'1I AQI - /. NA. (BD011ESR f(' 'L)C / <br /> CONTRACTOR 5-A)c- AOORE9e(Z L C-CI�LL�( r,I( <br /> SUB CONTRACTOR ADOPIESS lM/ PHOS .cam. <br /> TYPE OF SEPTIC WORN: NEW dSTAU.J IM RDANUADDITION OFSTRLIOTION ❑ <br /> MO SER1C SYSTEM PERMITTED IF MOM SEWER IS AVARASLE MISN EOD FEET <br /> �(OOFFRUI(L/DIN/,.) ,I� PMC TESTIPI 1 I NOW MARY <br /> W <br /> INSTALLATION ILL SMVE: RESIDENCE❑ COMMERCIAL 13OTHF?k <br /> NUYSM <br /> M ff WIND UNITS! NIIMSM OF BFDIIOOMS� NLMSM OF FAIROYFEJ:�S.f�C� <br /> WTI <br /> SORE TO A DEPTH OF 3 FEET allU RT/S�R CNARACTEII�//�JY I�/le?t[w V;ATM TABLE MPTM SC, , <br /> iAMRISPEASE TRAP ❑T'PE/MF E�. JLC^^ CMACT' ..�5'XP� NO.COMPAATMEMS <br /> FITMENT RANT 11 DISTANCE TO NEAREST: WELL/G2l T FOUNOATMN/EY�) Y FnORENTY LINE 1eX9 <br /> NFT STATION❑ SIZE TVPE OF PUMP BAND OIL SEPARATOR IENCLOSED SYBTEMI <br /> �y <br /> LEACHING UNE 4N0.\IENOTH OF lA1E8�- 1OC)' IiPtC! dST1WCETO NEAREST:WELL, _PoIMDATpN 1"'M <br /> , PIgPERTV UHE (00 <br /> / <br /> ENTER SEO ❑WIDTH LENGTH DEPTH dSTANCE TO NEAREST:WELL FOUNDATION P KFTTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH ) DISTANCE TO NEAREST:WELL PoUHDAMDF PRORRTY UNE <br /> SE AOS NTS DEPTH 2- MEE 31E71/ NUMBER J OIBTMICE lO HEARfST:WELL T) t PoIl1AATOH��FMKF TYUNE (6eC J <br /> SUMPS 13 WIOTH LENGTH OEPTII DISTANCE TO NEAREST:WELL FOUNDATION PmmFTrY UNE <br /> DISPOSAL PONTOS 11 WIDTH LENGTH MPT" DISTANCE TO NEAREST:WELL FOUNDATION PRORERTY UNE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL SE DONE IN ACCORDANCE WON RAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND MOVLATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER ORU NSEO AGENT'S WONATUM CERTIFIES THE FOLLOMNG:•I CENTIFYTHAT IN THE PTP MANCE OF THEMM MRWHMH <br /> TNR KRnUED,1 SHALL NOT ROY PERSON M SUCH NNEn AS TO BECOME SUSJFCT TO WOIKMAN'R COMPTNRATION UWS OF CALIPoIWIA.• CONTRACTOR'S HIRING OP <br /> SVB{ONSIGEW, SONG1CERTIAT IN THEREMORMANCEOFTHEWbWOR(MAR AT N RNI THF ALL 3S HOW IN ADVANCE FOR ALL REOIMry INSPECTIONS. COMRETE DRAWING BELOW. <br /> SIGHED]< TITLE' \ .G'F DATE: Z I•J <br /> \�� L ROT RAN gRAW TO SCALE,SCALE_ 'Io <br /> 1. NAMES OF STREETS OR ROADS NEARBY TO OR ROUNDING THE MIOPTRTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P RASED <br /> 3. OUTLINE Of THE P MFITY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANMON OF SMAOE OISPoSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND P RASED STRUCTURES. S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> MCLUNNO COVERED AREAS SUCH AS PATIOS.CIFIVEWAYS,AND WAU(S. THE PAORRTY OR ADJOINING PRORRTY, <br /> Ll <br /> A0 / <br /> pAct <br /> ;- <br /> ` . <br /> e <br /> �e <br /> FOR DdMTMMT USE ONLY DATE <br /> AM' ATION ACCEPTED By . �• // i' J <br /> : ARA: <br /> TANK,ITT OR BUMP MSKCTM14 BY ,ED'ATE / /1 FINAL INSP'E/CTMH BY DATE <br /> ADDITIONAL COMMENTS:�_1 t7 �F'(✓i(CLJ Acc'G,. /1` ��� ��/" �LR��tI J L 2_Ci� <br /> ACCOUNTING ONLY: NOF FACE <br /> PE CODE FEE INTO AMOUNT R"I TED ITEC MASH RECEIVED SY DATE M/PDIMIT NISYSM HIVOICEF <br /> q21C, P";-0f 3gs7 - -vs 0169y0 <br /> PUD.Heaflh$Rrv. Envlm.174(3196) <br />