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-•- APPLICATION FOR LIOUID WASTE PERMIT ... <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3BB, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.0388 <br /> (209) 488.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC&mpl&a in Tripliaat&) <br /> APPLICATION IB HEREBY MADE TO THE SAN JOAWIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIMNMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNY }O']E(? �C♦O.2 '50cu 46�5 CRY AG-A' 7 PO LOT SIZE <br /> OWNER'S NAME �"D I� L O//EV/`R ADDRESS /�1�1�L�� �/J�C�L_C?S PHONE/ S <br /> CONTRACTOR L M / =R� ADDRESS �d a J ,[�GAm/�U 'Cl- PHONE ✓'�Y <br /> SUB CONTRACTOR , i A r1L J�P ADDRESS�D, �JQ !1 Y UC/ }',,�PHONE <br /> TYPE OF&FITC WORK: NEW INSTALLATION RVABVAOOITIOM pr DESIILUCTION❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PEFC TUTW I 1 HOW MANY <br /> �y Application R <br /> INSTAWYTION WILL SERVE: RESIDENCE COMMERCIAL 13OTHER <br /> NUMBER OF LIVING URT& I_ NUMBER OF BEDROOM.:-1 3 EMP <br /> NUMSd OF LOYEE): �1 <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 'V PITISUMP SOIL CHARACTER: /WATER TABLE DEPTH �f S- <br /> SEPTIC TANK/GREASE TRAP ❑TYPE/MFG R CAPACITY �'G NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEATEST: WELL-/"—A*,— FOUNDATION .��E'ROPERTY—LINE <br /> �y���'�r <br /> LIFE <br /> ZE <br /> R(ENCLOSED SYSTEM) <br /> LEACHNG UNE 19 <br /> 019 NO.B LENGTH OF ONES F IWMI a rf O OIL ISSTANCE TO NEAREST WELL SO'7MUNUATION�PROPERTY UNE YJ <br /> FILTER BED ❑WIDTH LENGTH.// DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE pf <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 36 <br /> JJ� . <br /> SEEPAGE PLT. ❑ lS <br /> DEPTH ,� 1 SIZEVJ <br /> _NUMBER DISTANCE TO NEAREST: ELL ��fr fo/M��UNOATIONPPORERTY UNE i6 <br /> SUM" ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DIS MEAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNERORLICENSED ADENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION <br /> ,LAWS <br /> SOOF CALIFORNIA�THE <br /> iAPPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGMRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X L/• •IJhS(ALN TITLE: L+t1YF �hl��F'� DATE:— <br /> PLOT PLAN IDRAW TO SCALE)SCALE_'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. "PANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PPDPERTY OR ADJOINING PROPERTY. <br /> ry <br /> C- <br /> Z Q e-A <br /> iY � �U <br /> J <br /> .. <br /> SEP 2 8 _ I <br /> i1 <br /> n Com— <br /> JAN�UAC,., <br /> 'UBLiti HLA.L 1 <br /> FOR DEPARTMENT USE ONLY ) <br /> /l'^ n.Tl �l. I>-7 I ARFA: -7 7 , <br />