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1 <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 358,446 N.SAN JOAQUIN ST.,STOCKTON,CA 962018 <br /> (2O9)465-3420 <br /> NOM-REFUMDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUER <br /> mommlPh"IN TRUfIBTs) <br /> APPLICATION S HEREBY MADE TO THE SM JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO:OR RiaTALL THE WORK DESCRIBED-THIS APPLICATION S AIME M COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY flEVE10PMENT TIT4 c 9-1110.3�MD'IyE /j�=. ARAN COi1FR9'PUUfC HEALTH 6j`Q�M/iWyN/,') ►AL IIE/LL.rN OMagP;. <br /> JOS AOOREBOIOR APNr{-� ` ,� CRY l tel!l ■ / LOT SIZE <br /> OWNERS NAME Al L�t_ - `11` k ,>RE ?s LE! f%IL: L/QT If Z LOAr PR�MT 31 4 G o I r <br /> CONTR/11T1]R �I TAI® AIN11FS6.- i,:� LIC! •--+' PHONE <br /> SW CONTRACTOR AODIE[[ LRCM RpNF <br /> TYFM OF DORIC WOW_ NEW INBTAYATIOM RpMUADOMOM 0 DESTRUCTION 0 <br /> M SEPTIC SYSTEM PER MITT®/F PUBLIC OVMR IS AVAILABLE WITHIN 200 FHT OF NU LOM.) Pal.TWTIRN(1 NOW MANY <br /> A[/I[[Yaw• <br /> W"ALLATION WILL SHIM: RESIDENCE COMMERCIAL 0 TN[R 0 <br /> NIMNKEI OF LIVING YWi[:_�NUAB9R OF NIM11SRl OF MNPLOYait: <br /> CHARACTER OF SOC TO A DEPTH Of 3 FEET. F7 MP BOC HARACTER: WATER/TABLE OEPTH <br /> SMTIC TANKKSIFABE TMP ❑TYPFIMTO Ac IIY C ! NO.COMPARTMENTS <br /> r <br /> PRO TIRATME/T PANT CI pBTAmca TO NNJArAw.. WELL NORMIOATION IMOPERTY LINE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND SEPARATOR(ENCLOSED SYSTEMA <br /> wLCNMO UNE NOITY�— <br /> A LENGTH OF LINES ��OIeTANCE TO NEAREST:WELL FOVNO/1TWM PROPFNTYLINE <br /> PLTW AFD ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL RJUNDATION PROPERTY LANE <br /> MOUNDED ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL—.FOUNDATION PROPERTY UNE <br /> SCAM ATa CIO3DEPTH SM__NUMBER DISTANCE TO NENVAIT:WELL FORNNDATION PILDPWITY UNE <br /> P[ <br /> WIMWIDTH If./NOITN DEPTH DISTANCE TO NEAREST,WELL__FOUNDATION PROPERTY UK <br /> DISPOSAL POND# 0 WIDTH UENGTH DEPTH DISTANCE TO NEAAM:WELL FOUNDATION PROPERTY UNE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APRMATNHN AND THAT THE PLONK MILL BE OOZE M ACCOEIOANCE VM:'H SAN JOACUM COUNTY OIpWANCE[AND STATE LAMS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAOU#I COUNTY.HOME OWNER OR LICENSED ADFM'SSNN"TIRE CIRiE#Tiff MiDNWO:I CERTFYTNNTIN THEPEROIDMAENCE OF THE WOW FORWHICH -� <br /> THIS PERMIT IS ISSUED.1$HALL NOT EMPLOY ANY PEPMM M SUCH A MANNER All TO B@COME WBJECT TO WOPLMAN•S C0690MATM LAWS OF CALYOIRtlA_' CONTRAC'TOR'S NYBNB OR <br /> SUB•CONTRACrIM SIGNATURE CERTIFIES THE FOLLOWING:'1 CERRFY THAT W THE PERFORMANCE OF THE WOW FOR WHICH THIS PEMRT S HOUID 1 SHALL 00FLOY FOWORS SUUJBCT TO 411 <br /> WORIL MANS COMPENSATION LAWS OF CNWFOV"A_' THE APNUCANT MUBT CALJ_24 HOUq M ADVANCE FOR ALL IIEQUREO"UPECTION[. COMPETE ORAMAMG SE OW. <br /> - <br /> sIGNEaX_�,e�� TITLE. GrLIJI�f� P DATE: S - 3fi-f�� <br /> ROT FLAN I MW TO SCAM SCA:.E "a <br /> I,NAMES Of STREETS OR ROADS NEAIEST TO OR SOIN11110N TIE PROPERTY. 4.LOCATION OF"OUSE SEWAOF( k1 SAL SYSTEM OR PROPOSED <br /> I.OUTLINE OF THE PROPERTY,WITH DIMENINON[AND NORTH OWA CTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.N>MENSIONLD OVTUNES AND LOCATION OF ALL MXKWM AND PROPOSED STRUCTURES, S.LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> IICWDNNG COVERED MEAS SUCH AS PATIOf,CIP08MWO.AND WALKS. THE FROFETY OR ADJOMNG PROPERTY. <br /> d <br /> 40 <br /> 71 <br /> (lyLlr <br /> ...........c. .......v..... ....... ...... ,-. _- <br /> : <br /> ...-- ................. -_.. - - - ...-.. .._ <br /> ol <br /> • <br /> .......... <br /> : <br /> K- .-c4i-:.....;.. � - :. ?. ..:.......:..... ......:. .'. . �e'�`.. . �/lam.��,......... �' ...P_.. ...'. <br /> t <br /> .......... <br /> : Io <br /> 40 <br /> .. . .... ....:... <br /> :. . ..... ....... . <br /> >..... -'....... . <br /> T�usClCtt TH SERQiCE .... ..Q._.. ........ .. . <br /> ,L �p �Nn DoppaRIN10PT LSE ONLY - t L <br /> APPLICATION ACCEPTED BY_ C SIT—ALL-�^TIYY�.r(7�r..r' OATS: MFA.: Z T <br /> TANK,rn OR BUMP P.NSPECTION BY DATE / / FINAL INSPECTION BY �DATE <br /> ADDITIONAL COMMENTS: <br /> ACCOU16UM ONLY: AID., <br /> fACP <br /> PF L'00E FFE INFO AMOUNT REMITTED ABH R6RVRD BY DATE SRI P6MST NUMSYR N/T/OICfi P <br /> ?i l 11,E <br />