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?rf <br /> 4 APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOA <br /> QUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (,�J <br /> (209)468-34201 <br /> ' <br /> NOR-REFUNDABLE PERMIJ EXPIRES 1 YEAR FR011A AA 1 SUE <br /> ip 1 (Complete in Triplicate) <br /> APPLICATION 18 HEREBY MAGE TO THE SAN JOAOIIIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK bE8,J Ax IS '�CAPIMAGE IN COMPLIANCE WITH SAN <br /> JOAOURN COUNTY DEVELOPMENT TITLE��ER 9.11 10.3 D THE STAN ,@ O AN JO I OUNfY FVBLIC HEJ\LTH ERVICES.ENVIFq ENTAL HEALTH DIVISION, /,per <br /> (f/y Cm LOTSIZEJA-11A *f <br /> JOB ADDRES—A�# _ - ,' -� j <br /> i <br /> � PHONE <br /> OWNER'S NAME ADDRESS d `_ <br /> CONTRACTOR 1 <br /> ApDRE8$ i . W LIC# PHONE <br /> 'APHONE <br /> ADDRESS 'I LIC# <br /> SUB CONTRACTOR <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 13REPAIR/ADDITION DESTRUCTION❑is <br /> _ INO SEPTIC SYSTEM PFRMiTTEO-IF FVBtiC SEWER,h IB AVAILABLE WITHIN 200 FEET OF BUI N0.1 PERC TESTIS)1 1 HOW MANY <br /> r - APPO-den# <br /> INSTALLATION WILL SERVE: RESIDENCECOMMERCIAL El OTHER,❑ <br /> W , <br /> MIMSER OF LIVING UNITS: NUMBER OF SEDROOMS: NUMBERS OF EMPLOYEES: <br /> CH ER OF SOIL TO A DEPTH Of O FEET: PITIBUMP IL CHARACTER: W TER TASLE DEPT <br /> �ANK/d1WiE TRAP ❑T'VPE+MFG1� ✓ CAPACRY NO.COMPARTMENTS <br /> VKO TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL J 7 FOUNDATION/ PROPERTY UNE <br /> LIFT STATION❑ SITE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SY$TEMI ` <br /> f I DISTANCE TO NEAREST'WELL , FOUNOATION�PROPERTY UNE <br /> LEACHING LINE J�NO.S,LENGTH OF LINES - C) -�"'"�T �., <br /> FIlT61 BED C❑WEDTH LENIiTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST'WELL <br /> FOUNDATION PROPERTY LINE <br /> " DISTANCE TO NEAREST:YVELL FOUNDATION PROPERTY UNE• <br /> SEEPAGE PITS 13DEPTH SIZE NUMBER 3 ' <br /> SUMPS C3WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> i! FOUNDATION PROPERTY UNE <br /> :i <br /> DISFONDS [3 WIDTH LENGTH DEPTH " DISTANCE TO NEAREST,WELLFOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN UOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> ULATIONSOFTHESANJOAOURN UNW 140MEOWNER ORUCENSEDAGENT'S SIGNATURE CERTIFIES THE.FOLLOWING.4CERTIFYTHATINTHENERFORMANCEOFTHE W'ORKFORNMICH <br /> TH1 IT 1 IS ,1 ALL HOT EM Y ANY PERSON M OWN A MANNER AS TO BECOME SUBJECTTO WORKMAN'S COMPENSATION U1W8 OF CALIFORNIA-' CONTRACTOR'S HIRING OR <br /> BU O A RE CERTIFIE HE FOLLOWING:' CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT TO ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WD M 'B SA WS F C FORMA THE ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOVIRED INSPECTIONS. COMPLETE DRAWING BELOW <br /> I€ � r.� TITLE. <br /> rGATE: <br /> SIGN X <br /> j 'to <br /> PLOT PLAN mRAW TO SCALER$CARE <br /> I 4. NAMES OF STREETS OR ROADS NEAREST TO OFA BOUNDING THE PROPERTY-' 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. -; EXPANSION OF SEWAGE DISPOSAL fY8>'EMS- <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, G. LOCATION OF WELLS WITHIN RAWUB OF ONE HUNDRED FIFTY Ft.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,4)RIVEWAYB,AND WALKS. ! 'j THE PiIOPERTY OR ADJOINING PROPERTY' <br /> .. ...:.... .......... i .. - .. ................ .. .. .,. . <br /> .. <br /> _ ...,. - .. ., .. .. - .. <br /> ... .. <br /> . <br /> C <br /> News ..... .. .�.: ...:. .. I .s :.. '... ....... <br /> ...........:.. ..... r <br /> ra .,.... .. ......': :....... <br /> ' F. .: <br /> j. 1 ... .... <br /> t . <br /> { pig M '� LTH SERV S...- <br /> .... .:... ... ...... RL HEALTH DIVISION <br /> NVIRQ <br /> ^ FOR DEPARTMENT USE ONLY .• <br /> 4 / � .0 DATE: ��� � F AREA: <br /> APPLICATION ACCEPTED BY t <br /> ) II �l <br /> TANK,PIT OR SUMP INSPECTION BY DATE 1 FINAL INSPECTIO Y DATE <br /> r l <br /> ADDITIONAL COMMENTS: l <br /> kA <br /> .elif <br /> .............. <br /> ......... ....... <br /> I FAC• <br /> ACCOUNTING ONLY: ALD# <br /> PE CODE FEE INFO AMOUNT RUJBiTED CHECK# ASH - RECE4VED BY DATE ; SR.1 Pff"T NUMBER INVOICE# <br /> �I <br /> Pub.Health Serv.•EnVIro.174(3188) <br /> I <br />