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APPLICATION FOR LIQUID WASTE PERMIT <br /> f. SAN JOAQUIN COUNTY PUBLIC HEALTH SER* <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 384 EAST WEBER AVENUE,STOCKTON,CA SS202 <br /> (209)468-j420 <br /> E NON-REFUNDABLE PERMIT EXPIRES I TEAR FROM DATE ISSUED <br /> PunpleEr Is Trlplastll ' <br /> APPLICATION is HEFXSY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMrr TO CONSTRICT ANDMR INSTALL THE WGA(DESCRIBED.THIN APPLICATION Il MADE IN COMPLIANCENATH SAN <br /> JOAOVIN COUNTY DEVELOPMENT TRIS CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAiOVIN COUNTY PUNIC HEALTH SERVICES,EWVIONMENTA.HEALTH DIVIMM, 7 5 C <br /> JOS AOORE1BIVR APH/I2`1'1l2 11 N`.1�1-:II-' ��li'� �:f�`�ra��1t --tRv �F5 ro LA F T� _-ttDrsag I il�'7" ` <br /> �yt �7R`H11 GT'CIl.I:r1`. <br /> &Awta-S HAME M ti cnc:(7I I;e.--Pa I <br /> CONTRACTOR ArJ6RSt `xcGEl�C'C.; � Jr� ' r LICF M'DNE <br /> -IR.CONTRACTORbL:4_I ;nTt rI11rLf NtC�}I AOOIESI c ! n II l.�+CA �•.,. PIaN� ? 1 <br /> rrRE OF SEnDwDRr NEW INSTALLATION <br /> REOESTRUCTAN❑ <br /> - .. <br /> IND SEPTIC svrtEM PERMITTED IF N1lNC AE4VE <br /> RIs AVAILABLE wRNIN 20O FEET O UN.DINOJ PeIG rnTN1 I <br /> HOW MANY r <br /> P <br /> WITALLATION WILL•DAL RESIDENCE❑ COMMERKTALL%�' OTHER ff 7.11f, <br /> NUMSIR OF WHO USIFIV NI.PMBHt OF SEDROOMS: NUMS91 OF I MPWYm: k k l"/�"_i'^ 'S [':•�y/�.;q'T~ - <br /> CHARACTER OF SOK TO A DEPRI OF 3 FETT: MYISUMP SOIL CHARACTEX, WATER TANS DEPTH <br /> SEPTIC TANRATEASE TTLILP�r ❑TYPEeMr-o CAPACITY NO.COMPARTMENTS <br /> Mo TREATMENT MARY 13 DISTANCE TO NEAREST: WELL FOUIIDANON PROPERTY RINE <br /> UFT STATION❑ SUE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSFD SYSTEMI <br /> LEA414"d LINE ❑ NO.A UU41M OF LINES DISTANCE TO NEAREST:WELL FOUHDATION PFOKRTY LINE . <br /> M%T6t SED D MOTH LENGTH DEPTN DISTANCE YO TRFAAM:WELLFOUNDAVQJ PROPERTY UNE <br /> MDUNDtE 13 VWW 14 LENOTM DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UME <br /> SWPAQE FRS - 4••�KrrN SRE .NUMBER DIAR <br /> STANCE TO NEESTI M411 FDUNOATIOH PROPBUYEINE <br /> swn ❑YROT/I LENGTH Omit DISTANCE TO NEAR7EST:%EU FOUNDATION PROPERTY UNE <br /> OISPOSAL PONOS []WIOTN LENOTN DEPTH DISTAHCE TO NEAREST:WELL FOUNOAMIo PROPERTY LINE <br /> 1 HERESY CERTIFY TNM <br /> AT I NAVE PREPARED THIS APPJCATION AND THAT THE WORK WILL BE DONE RP ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES <br /> AHOR[OULATONI OF THS SAI JOAQINN COUNTY.NOTAE OWWER OR LCENWO ADENT'S OKWATURtE CERTIRES THt FOUpYANO:y COMFYTHAT M THE PET"M1ANCE OF THIVIOAt FOR WISCH <br /> 7140 PUsAT IS IS1UM I SHALL NOT EMPLOY ANY PERSON IN NUCHA MANNER N To BECORR SUWECT TO WOWMAN'S COMPENSATION LAWS OF CAIFO NIA.'CONTPACTOR-S ARANO OR <br /> SUSCONTRACTNa SR WATURE CERTIFIES THE TOLLONRNO:1 CERTIFY THAT IN THE PnfaAMANCE OF THE WOW FOR VA CH T1ns PERMIT Is ISSUED.I EMAIL EMPLOY PERSONS SUWtCT TO <br /> WORKMAN'S COMPENSATION LAWS <br /> ��OF CALIFORNIA.' THE APPLICANT MUST CALLLL 74 HOW N ADVANCE FOR ALL REONRED tNAMTIDHS,COMIKETE DRAVDNO UWW. - <br /> �l:�' -EI]�'1 TR � <br /> IS; I('�I t-I /1'�F"(.I LA/ OATS: � <br /> l.� <br /> PLOT PIAN ENWW TO SCALE}SCALE <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY, 4.LOCATION OF HOUSE RWADE DISPOSAL SYSTEM OR PROPOSED <br /> S.OUTLINE OF THE PROPERTY.WITH OIMENSONS ANO No1RT1 OWNC'TION. 0WARNOH OF SEWAOE DISPOSAL SYSTEMS. <br /> a.WMENWW*b OUTUN[S AND LOCATION OF ALL LIUSTIPIO ANO HOPONO STRUCTURES. S.UOCATM nF WEl wrnaN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 9 CLUDIND cOVENED REAS SUCH AS►ATFL I/PROPRTY• <br /> --- <br /> I <br /> teK4%6 , <br /> • <br /> t <br /> AAAA <br /> ti <br /> ...... AAAA..-�-. <br /> . . AAAA <br /> .., ... : AAAA. AAAA;. <br /> Y C l <br /> L. <br /> I w w <br /> AAAA AAAA: - -l <br /> q ` <br /> r <br /> rPbYMENT . <br /> It <br /> - - - T1i�nN6�GMrSIP _ . <br /> Wei T240TJ ... . <br /> POW <br /> un <br /> HTTr <br /> IN V <br /> FOR OEfARMENT WE ONLY - <br /> APPLICATION AccrMtO BY- y •[ DATE: <br /> FANK,PIT OR SUMP MS4CC[IOII aY DATE I I FINAL INSPECTION BY OAT' 1 <br /> ADTMIONALCOMMENTI: <br /> ACCOUNTMO ONLY: -AMS <br /> PE Coas FUN" AMOUNT RfARfYfO CNDCNI MH RECFIVTD IT O►TE M7PNS1tT NLSASER • INVOICE/ <br /> Pub.HsaMh Sarv.-En*o.174(3796) - <br />