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2.. APPLICATION FOR LIQUID WASTE PERMIT <br /> J <br /> SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.D. BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 9620141388 <br /> (209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C/IDpku N TripllPadl <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMIPU"XE WITH BAN <br /> JCAQUIN COUNTY G,"LO�PPWNNTT TRLE,CHAPTER 8.1110.3 AND TH/E 1BrANDARDB OF BAN JCAOURN COUNTY PUSIIC HEALTH._�SEAMCES,ENVIRONMENTAL FEALTH DIVISION. <br /> JOB ADDRFSSIOR APNI cam! /� e/7 I ll//Gr 1201 [�/�n/� / � ( CITY,�1 C= /� ,,/ /� jLOTT aRE / <br /> OWNER'S NAME /nom( yf2go/rLC�I'1SCS ADDRESS 1!2[7L/ N Df�L7�1/ lV C>`N'1 4- `' + .PHONE,?6/- 770 <br /> CONTRACTOR,L / EC l / /t/7�-'r►fi t/CPc ADDREHe /�7� O A I /� LIC/,-1`?J!�R10N[,j L7LZ-ZZDy6 <br /> SUBCONTRACTOR ' ((_{7��1crC, _/ //Js �xjp-, I py-t //a S 2— <br /> ��AooREaa uc,R -- PHONE <br /> TYPE OF SEmC WORK, NEW IMSTALLATIOILW PWWPJADDTHON ❑ D"TRUCTION❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUSL'C SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING) PORC TEISTN)I i NOW MARY <br /> APpllo�tlan S, <br /> INSTALLATION WILL SGRVE: RESIDENCE* COMMERCIAL❑ OTHER 11d <br /> NU(BIM OF LIVING NG UNITS: NUSIBI OF BEDROOMS: NUNISM OF 6.1PLOVEia: �G7' <br /> CHARACTER OF SOIL TO A DEPTH OF O FEET:_ PTTMWP SOIL CHMACTER: WATER TABLE DEPTH <br /> SEPTIC TANKIOREASE TMP EI TYPEWFO CAPACITY NO.COMPAAHMENTS v2 <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAIREIT: WELL " FOUNDATON�a, - P OPEFfY U E <br /> LFT STATION❑ SIZE TYPE ,,//,�11 /�SMO OIL SEPARATOR(ENCLOSED SYSTEM) <br /> M13 _ <br /> LEACHING IE NO.A LENGTH OF UNE k--v /N DISTANCE TO NEAREST:WELL FOVNDATbN 4 PROF"TY LINE <br /> FILTER BUD ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELL F61NDATIiON PROPERTY LINE <br /> MOUNDED Cl WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL �� ��FOUIDATOION�QN PICWERTY LINE <br /> SEEPAGE PITS 13OIYTH�Sin .3(n,• .wumu t DISTANCE TO WAE%EST:VAaL_]Ey/([FOUNDAThT: PROPERTY UNE <br /> SOAPS ❑WIDTH LENGTH DEPTH DIBTANCE TO NF/JEST:WELL RT-FOUNDATION `/ PROPERTY LRE <br /> OISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL__FOUNDATION PROPERTY UNE n <br /> I HEREBY CETTTWY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORN WALL BE DONE IN ACCORDANCE WTiH BAN JOAQUIN COUNTY ORDINMCEB AND STATE LAWS.AND RUES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OVA"OR LICENSED AGENT'S BONATURE CERTIFIES THE FOI.OWINO:'I CERTIFY TWAT IN THE PEifO WiN <br /> ACE OF TFE WORK FOR WENCH <br /> TWO PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WOWIAAWO COMPFNBATORN <br /> N LAWS OF CALIFORNIA CONTRACTORS HIRING OR <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOUAWING;'I CERTIFY THAT IN'HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO <br /> YVORKMANI'B COMPENSATION LAWS OF CALIFORNIA.'�pTIHE APPLICANT MUTT CAL%24 LOURS IN ADVANCE POLI ALL RIOIDD AWAINSRICTOM <br /> NS. COMPLETE DMBO <br /> LOW. <br /> BBOW. <br /> Y <br /> SIGNED �yj,[,L1 �n 2/.1i(i(, Ll TELE: <br /> PLOT PAN mRAW O SCALEI SCA:F <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF/LOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED tf <br /> 2. OUTLINE OF THE PROPERTY,VWTH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I� <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL FJLISTIHGANO PROPOSED STRUCTURES, S.LOCATION OF WELLS YVTT7IN RADIO/OF ONE HUNDRED FIFTY R.ON `1` <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,CHIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINIKI PrOPERTTY, <br /> ..........>.....:.... . . <br /> ......:. .: <br /> ............ .......... . .........................*........ .- ............ <br /> ............ <br /> . .. ........... ...... : ........... .. ............. <br /> ... ........ <br /> ................... ................ <br /> ............. .... ...... <br /> ................ <br /> N 1...... .............. <br /> . . <br /> ............ ........... . . ............. ... .:. . <br /> ' ..s.... ... ' <br /> :...... ...........:......... . ...: .. ........... <br /> i......:............. . M Cvu.;;........s....... <br /> ;...........i....._ .., LBH <br /> a.....`,...,. .. <br /> 4 c H�aLrl l sQRv[CE,s _. <br /> NViFDNMEIdTA�•N¢AL7'H D'IVl$Ip� <br /> _. ............................ :. . ... _.. <br /> mei <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE: AREA:- <br /> TANK,PIT OR SUMP INSPECTION BY DATE / f FINAL INSPECTION BY - / .��. DATE /R_17 I(� <br /> ADDITIONAL COMMENTS: <br /> ACC0U11-1.ONLY: AMN FAC. <br /> PE CODE FEE INFO AMOUNT RB.11TTED CHIRCK/ ASH PAC6Vm BY DATE wt/POWIT NUUER INw10E s <br /> Z D Sys DU 7 ql O S76 <br /> II <br />