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APPLICATION FOR LIQUID WASTE PERMIT �UV � <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> WON REFUNOARE PERMIT EXPIRES 1 YERN FROM DATE ISSUER <br /> pComplYu M Trlp0atD1 <br /> APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PEFMO TO CONSTRUCT AXO R MSTALL THE WORK DESCRIBED-THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAOUH COVN7Y DEKLAPMEM TITLE. HE SA OF 6 JO AL`HCE�ALTpH #VION. <br /> VESENWWArN <br /> Ct CITY!/,`' /lA - LOT <br /> JOB ADM&WOR APN. / <br /> ' <br /> oYMER's NAME �/ � -�� •�/` ADORESH /f /[7�� /..� r PHONE N <br /> CONTRACTOR_ / - �� S��L 'Y'AODREBS / �• 1�"`�Y-�,I/ /� •_l1L/ Z R10NE <br /> BUB CONTRACTOR ADDRESS LIC. PHONE <br /> TY OF SEPTIC WOR%: NEW INSTALLATION❑ RmAIRMMUDO OE4TRUCTOM❑ <br /> NO SEPTIC SVBTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of RD1NG.) PHLC TpTHI 1 1 NOW MANY <br /> IHSTALLATIDN WILLPONE RISIOENC£❑ COMM61gM L.T�" OTHER❑ <br /> NUMSAI OF UVNO UMTS: NUMBER OF REDMO/MS: NURSER OF EMAYE": /1 <br /> CHARACTER OF SOIL TO A DEPTH OF 3y/,Pi--1 TISUMP NSOR TABLE DEPTH�� T <br /> SornC TA&WJGFSASS TRAP 13 <br /> 13TYPE/MF0 CAPACITY No.COMPARTMENTS <br /> PKO TIIEFLI <br /> ATMENT NT LJ OISTANCE TO NFAIWAT: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑ SIZE TYPE OF PUNK' BAND OIL SEPAAATOR(ENCLOSED SYSTEM$�� T ) <br /> ����yyy�.1111 t-- ,£ DISTANCE TO NEAREYT:WELL��j Q70NDAT70N D RioKRTY LINE <br /> ^ <br /> LEACHING LIME No.•IIItOTH OF LINES ASQ+�•L+'7 � --/ �-+�--- <br /> INLTIR SID rl WIDTH LENGTH DEPTH DISTANCE TD HEAREBT:WELL PDUNDATpNPROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME <br /> SEEPAGE INTO ❑]DwTH mZE NUMBER OUTANCE TO NEAREST:WELL FOUNDA.14 PIROPERTV LINE <br /> �� <br /> SUMPS ` r:RWM -_LENGTH SGS r DEPTH l jg, EASTANCE TO NEAREST:WUVI: �MMt)ATION�PROPERTYUNE b y <br /> 0191'041I1 PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> — <br /> I HETO:sY CERTSY THAT I NAVE PREPARED THIS APPl1CAT10N AND THAT THE RSC WILL BE DONE N ACCORDANCE WDH SAH JOAOUN COUNTY ORDINANCES AND STATE UWS,AND MILES <br /> ANDREOU THE SAN AODM COUNTY.NOME OWNER OR UC BIT'S YONATURE CERTIFIED THE FOU.OWNO:'7 CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FORWHICH <br /> TWO W 1 S N EMPLO PERSON M 81JCH A M AS TO BECOME SUBJECT TO WORKMAN Y COMPENSATION LAWS DF CAUFORMA•CONTRACTOR'S HIIMW CR <br /> 8 W7rPACTNO S 4 C T OWING:'I CERTIFY T N PE11fORMMKE OF THE WOM FOR WNIOPI TMH PEF"T Is ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> AN'Y CONIPENs NEB C TNI TNS IIDLRO d AWANCS FOR ALL NOI!•1®IIESPELTNINS. COMPLETE DRAWING BROW. <br /> TITLE: (/1}r ny' <br /> DATE: L� <br /> BIG x <br /> PLOT PLAN OEIAW To SCALE(SCALE 'ro <br /> 1.NAMES Of STREETS OR ROAD$NEARE OR SO NYMIO THE PROPERTY. 4.LOCATOR OP 110116E SEWAGE DISPOSAL YYBfFM OR PROPOSED <br /> R <br /> .OUNIE OF THE PROPERTY,WTTM O(MY1 <br /> ENpNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTIMS. <br /> 3.OIMENSM7R.4D OUTLINES MID LOCATION OF AU EXISTING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLY WT1N RADIUS OF ONE FM1M40ED ENT'FT.ON <br /> INCLUDNO COVERED AREAS SUCH AS PATIOS,DRWEWAYS,AND WAL%e. <br /> 7THE PROR ADJOINING FROPERTY. <br /> - <br /> �J <br /> . . ... <br /> ... A <br /> PAYMENT <br /> Auq <br /> O � e- <br /> ,� _D <br /> 31998 <br /> _ - �eue�E ti -CSS <br /> ' SA1v.lOP.QUIN CGUNi'T r }t <br /> PUEOJC HEALTH SGAVIC Slon <br /> _.ENVIRGNmENTALH _._TH. _.... .. ( .. <br /> FOR EIFPAPTMBIT URB ONLY <br /> A14I1CAt10N ACC-1AREA: <br /> 'ED BY � GATE: y <br /> TANK,PR oR SUMP NSPECTRoH BY DATE l /f(NAL IHSKCTaN BV GATE <br /> ADDITIONAL CO►MREWS: <br /> ' ACCOUNTING ONLY: Aro! FAG. .�.�I/rJ7/ ��`✓� <br /> R CODE <br /> Flaw" AMC UNT RLMI77W KAIN AXCBVED SY DATE M!F/Y.fT NUI.SBi 7NVMCE/ // <br /> z 5 VVS <br /> \ Pub.Health Serv.-Enviro.174(3/96) ' <br />