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APPLICATION FOR LIOUID WASTE PERMIT <br /> } ! JOAQUIN COUNTY PUBLIC HEALTH OVICES Lk- �. <br /> ENVIRONMENTAL HEALTH DIVISI <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 EPTIC <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Csmpl6te M Triplicate) <br /> ARYR.IC ATION IB HEREBY MADE TO THE BAN JOAOl11N COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIN APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> EALT/I DIVISION. <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND T�THE STANDARDS OF N/AFJ��JOAOUIN COUNTY PUBLIC HEALTH BERMCC[EES.ENVIRONMENTAL Hi�/L� ," CITY r l"! t.Or S17F L-- <br /> JOn Annnr nmmn APFI# <br /> IONS <br /> OWNFR'S NAMF <br /> �! _'�J• ��-�(�J� A <br /> D <br /> DRE <br /> S <br /> S VD�A`, L — <br /> � UCI ONFPZ'z n_ <br /> . <br /> CONTRACTOR (/ e�. e4w LIC/ ION1, Cf <br /> 3 <br /> AIMCONT1tACT0nAS�/ G <br /> TQM ♦ NEW INET AllAT10N REPAInIADDITION ❑ DES TRl/C TLON❑ <br /> TYrF OF FPTIC WORK: <br /> ISO BEP11C BYST FM PEMAITTEO IF PUBLIC BEWEn 18 AVAILARLE WITHIN 200 FEET OF BUILDING.) <br /> PFRC TESTI.I 1 1 NOW M <br /> APPaewtlee <br /> INRTAtIATION WRLSFTIVE: nFSIDFNCF). COMMFRCIAL ❑ OTIIFn❑ <br /> 141"11111 OF 11VINO UNITS: NUFAR 1 OF BFnn' �FVMITIBUMPJOIL <br /> NUMNTR OF"APLOYi►S: <br /> CII CTEn Or SOIL TO A DEPTH OF 3 FEET: CHARACTER <br /> ��/ WATER TABLE DEPTH 7L� <br /> c '(per?) NO.CORT MFNTS <br /> 1NIVOnEA6E TRAP ❑iY14/Mi �E/l't�• �I�� _CAPACITY <br /> PKO TREATMENT PLANT[I DISTANCE TO NEAREST: WELL 5'O/ FOUNDATION _ PROPERTY LINE /"n <br /> IIrT ATATION❑'''rrr7761117F_ TYPE OF PItMP SAND OIL SEPARATOR IENCLOSEO SYSTFMI <br /> IFACnNo Uhf. yu NO.S LEND TII OF LINES J �O t ' Y��7_ DISTANCE t0 NEAREST:WELL FOUNDATION PROPFRTY LINE <br /> FILTER NED /❑WIDTH LENOTH DEPTH DISTANCE TO NEAnEBT:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEFPAOE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE / <br /> 6UMrS %moil) LENOTH�10 / DEPTH , ,DISTANCE TO NEAREST:WELL/fib FOUNDATION /6 , PROPERTY LINF !2 <br /> DISPOSAL PONDS WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 1 IIFnERY CERTIFY THAT 1 HAVE PREPARED T1118 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THESAN JOAOUINCOUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIER THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR VA ACYL <br /> T141P STRMR IN INRUEO,1 SHALL NOT EMPLOY ANY PERSON IN 811%MANWAAS TO BECOME SUBJECTTOWORKMAN'S COMPENSATION LAWS OFCALIFORNIA.- CONTRACTOR'SHALINGOR <br /> SUR-CONTRA TING SIGNATURE CERTIFIES THE FOLLOWING: 1 CEHE PERFORMAE OF THE WDA(FOR WHICH THIN F4RMIT IS ISSl1E0.1 B{IAII EMAOY 1'F.n80N9 RUNJECT TO <br /> WOFKMA 'B MF'ENBATION LAWS OF CALtFORN1A.' THE APPUURS ADVANCE FOR ALL REOU IRID INSPECTIONS. COMPLFtE DRAWING BELOW. <br /> SIGNED X C TITLE DATE: -� <br /> PLOT PLAN(DRAW TO SCALE ALE_ 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE P11OPEA. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMB. <br /> 3. OIMENRIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPO TRU UREB, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. N <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR AOJOINING PROPERTY; <br /> I�D <br /> j <br /> (f <br /> I - <br /> 3 <br /> r . <br /> M <br /> R .i r, 19�.q <br /> - � <br /> >x x/(d <br /> /�/ f0 DEPAP t USE ONLY (/S <br /> AIII ICA 11014 AC@ FPl EDI l A t DATE: 1 `' 9 <br /> rr AREA-Z <br /> TANY.,MI On BLIMP INSPECTI 1 BY DATE / / FINAL INSPECTION BY /-- <br /> pp DATE / <br /> ADDITIONAL COMMENTS: �/f wMTPNFI� —�� <br /> — � ays ar>'"1 e� <br /> ACCOUNTING ONLY: - AID# FAC# <br /> PECODE FEE INTO AMOUNT REJMII ED IIEC/CASH RECEIVED a DATE <br /> I 1 J( !7 OR/F 9MT IRJINBg1 <br /> L f1 WMICE <br /> 1` <br /> Pub.Health Serv.-Enviro. 174(3196) <br />