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APPLICATION FOR LIQUID WASTE PERMIT a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SS201388 <br /> (209) 468 3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICtmp)ftf in Triplicate) <br /> APRJCATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLJCATON IB MADE IN COMMANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENTW TIITLE.CHAPTER 9-1110.3 AND <br /> /---.iH��'E BTA[N/�pARDS OF/9/A/I.1 JO(///,/VIN COUNTY PUBLIC HEALTH BSE/B[�y,1+C,E,B,EN/NJRDNMEMAL HEALTH DIVISION. <br /> JOB ADDRE68/OR ACCPNI /})'^ /�� l%(J /C-C / ��'l CfTV ✓ 'LA'L'YYO LOT I�ZEjg4 E Q <br /> OWNER'S NAME_U <br /> l'EQKAA.- ,/ ADDRESS r /f d �� ) F c�L � %r <br /> CONTRACTOR-/IDL�� '�Cr ADDRESS/7/ [. 1�/LVYN'./�u . ISk Me : moio& y3 <br /> SUB CONTRACTOR ADDRESS LICE PHONE <br /> TYPE OF SETC WORK: NEW INSTALLATION PEPAR/ADDITION ❑ DESTRUCTION 11 <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AV LABLE WITHIN 20O FEET OF BUILDINU.1 PIC TESTI.)I 1 NOW MANY <br /> APglwlbnl <br /> r— <br /> INSTALLATON WILL SEINE: RESIDENCE❑ COMMERCIAL❑ OTHER 7 <br /> NUMBER OF LIVING UMTS:7 `.Lfl "Wow OF BEdI00Mf:� NM M OF @AMAYEFS: <br /> CALARACZEIS OF BOIL TO A DEPTH OF J FEET A. PFTrMP SO .CHAMCTE . WATER TABLE DEPTH <br /> C TAM EME TRAP ❑tYRErMRN `J w C�F�CAPACT' W.COMPARTMENTS, <br /> PRO TREATMENT PLANT❑ DISTANCE TO NEARNT: •WELL too f FOUNDATION S K PROPERTY LINE <br /> LIFT STATION❑\..IZE TYPE OF PUM,P1 _BAND OR SEPARATOR 1ENCLOSED SYSTEM) <br /> LEACHING UNE —11)NO.B LENGTH OF UNES �— �tO K�'�Q DISTANCE TO NEAREST:WELL-��, `I" FOUNDATION- (C) PROPERTY UNE �-' <br /> FILTER BED /13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SWAGE FITS IDEPTH 4�/ SIZE IK NUMBER DISTANCE TO NEAREST:WELL FOUNDATION l PROPERTY UNE <br /> PUMPS 13 WIDTH <br /> LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE y� <br /> DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT 1 NAVE PREPARED THIS APPJCATION AND THE RC WILL BE DONE IN ACCORDANCE WIN SAN JOAQUIN COUNTY ORDINANCES AND STATE"We,AND RULER <br /> AND REOUTATbNe Of THE BAN JOAQUIN COUNTY.MO ME OWNERORUCENBEO M'8 SIGNATURE C ERTIFIES THE FOLLOMNG:'I CERTIFY THAT IN THE PEIVORMANCE OF THE WO W FOR WHICH <br /> THIS PRMIT IB ISSUED,I SHA OT EMPLOY AI�'JEL),SON IN SUCH A MANNE AB O BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGN TU CE IFIEB LLO G:'1 CERTIFY THAT I THE RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN' COM F IBA ION W OF A F IA.' TI APPUCANT MWT ALL 2f SUITS IN ADVANCE FOR ALL MGM�INSPECTIONS. COMPETE DRAWING BELOW. <br /> SIGNED X _ <br /> TITLE: DATE: r C S 0 <br /> -' � 1 — � C, <br /> l ,! POT PAN(DMW TO SCALE)SCALE 'le <br /> 1. NAMES OF STREETS OR ROADS NEAREST OR BOUNDING THE PROPERTY, •. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED �^ <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BVBffMe. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, B. LOCATION OF N/EWA E DISPrHIN SAL S ST ONE HUNDRED FIFTY R.ON <br /> INCLUDING COVERED AREAE SUCH AS PATIOS,DPoVEWAVe,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> 1 <br /> 10 A 0 <br /> 3z <br /> as, If <br /> i AL1` ''fr <br /> '�AY15A�N`i <br /> JUN 2 4 1998 7I <br /> SAN JOAQU N UU?N F II\Y <br /> VI IRI Il`HRAI TH <br />