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orr 7 <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKMN, CA SMI-388 <br /> (209) 4883420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CBro11BtB iR TripIIBBEBI <br /> APPLICATION IS M.REBY MADE TD THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND"INSTALL THE WOFV(DESCRIOED. THIS APPLICATION 19 MADE IN COMP'JANCE WTH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 1 10.3/ANDD THE ATANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICCIEB,ENVIRONMENTAL HEALTH MVIB*N. <br /> !OB ADORESSIOR APIA' //,4 -?- ��O!C�1Ls� �jpL-. Q CTry "t-- _LOT 912E1/ es<. <br /> DYMER'S NAME �r,�+rLl_, �J�'y7 2 ADDRESS PHOrNE�r�� <br /> cONTRACTORi7�S'�-. .,,� �..}�� ADDRESS/71 Z<7 O, 6-4, -e-%O lbw LIC]��I FFIMIE •� �� <br /> SUB CONTRACTOR ADDREGS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE'PAIRIAODITION DEITRUCTION Cl <br /> INO SEPTIC SYSTEM PERMTTFD IF PURUC SEWER 19 AVAILABLE WITHIN 200 rccT OF SUR.bINO.) PWC TESTb:I 1 HOW MANY <br /> AppBootleR <br /> INSTALLATION WILL SERVE: REBIDENCE�V COMMERCIAL ❑ OTHER [I <br /> NUMBER OF UNNO UNITS:�L NUMBER OF BEONOOMS: 14MMER OF EMPLOYM.—. <br /> CHARALW OF SOK TO A DEPTH OF l FEET!( if�Ptt/SIMAPVBOIL CHARACTER: /'I• 4,0-t WATER TABLE DEPTH <br /> > T KMMFASE TRAP ❑TYPEIMFO�/ �T„e. G - A'` CAPACITY / uz��•� NO.COMpARTMENi9 <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WVELL-��' FOUNDATION P'ROF4RTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PLNAP ND SAOIL SEPARATOR IFNt:LOSED SYSTEMI <br /> LEACHINO UNE NO.1,LENGTH OF LINES I' �L/0 �� � Le' DISTANCE TO NEAREST:WELL 0 FOUNDATION PHDPERTY UNE l / <br /> FILTER BED KEITH-WIDTH LENGTH _DEPTH OIBTANCE TO NEAREST:WELL--FOUNDATION PROPERTY UNE <br /> MOULDED ❑WIDTH LFNOTH _DEPTH DISTANCE TO NEAMBT:WELL rOUNOATION PFIDFE RTY UNE <br /> SEEPAGE RTSEPTH S SIZE '3�.. .NUMRER_�D16TAtN[E TO NEAREST:WELL FOUNDATION 7G0 PROPERTY UNE �7 <br /> SLIMS ❑WIDTH LENGTH DFPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL POND ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> HEREBY CERTIFY THAT I HAVE PREPARED TMB APPLICATION AND THAT TH. WORWILL LL BE DONE IN ACCORDANCE RDI <br /> WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REO FT" BAN JOAQUIN COUNTY.HOME OVVNEROR LICEN GENT'S StOHATURE CERTIFIES THE F4LLOVVM10:'I CEMWYTHAT IN THE PVWOWAANCE OF THE WOW FOR WHICH <br /> TIIIS PE IT IB ISSU I T E PERSON IN SUCH A M E AS TO BECOME SUBJECT TO WOq(MAN'B COMPENSATION LAWS OF CAUFORWIA.- CONTRACTOR'S HRVNO OR <br /> SUB�C NTRACTING Sq URE RT IE HE F OWING! -1 CERTIrY T T IN -HE PERFORMANCE OF THE WORK FOR WHICH THIN PEWIT IS ISBUED,I$HALL EMPLOY PERSONS SUBJECT TO <br /> WO AN'S COMPEN N F A IFORNt - THE A T CA '.24 HOUR]IN ADVANCE F-JR ALL FIEOUIIED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> LBIGNFO Tf LE' `rCk l7L• DATE! <br /> I I <br /> PLOT PLAN(DRAW TO SCALE]$CALF 'to ` <br /> 1. NAMES OF 9'T MEET$OADS AREST TO OR BOUNDING THE PFKMmERTY. 1, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR A1OPOSE/ <br /> 2. OUTLINE OF THE P110PERTY,WITH NSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. c <br /> Z. 0116WNSOINED OUTLINES AND LOCATION OF ALL EXISTING MIO PROPOSED STRUCTURES, S. LOCATION OF WELLS NTTNNt RADIUS OF ONE HUNORED FWTY FT.ON t <br /> INCLUDING COVERED AREAS SUCH AN PATIOS,ONVEWAYB,AND WAURB. THE PROPERTY OR ADJOINING PROPERTY. <br /> i <br /> M (, <br /> V <br /> LI <br /> �v � <br /> `vI� <br /> • <br /> I <br /> lo96 <br /> �_ <br /> FOR DEPARTMENT USE ONLY <br /> APPU7 <br /> CATFON ACCEMED BY C-"C;� DATE: r } / i U AREA:_ _ <br /> TANK,FIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION B <br /> ADDITIONAL COMMENTS: <br /> ACC:JUNTINO ONLY: AID/ ]:ICR <br /> PE CODE FEE INFO AMOUNT REMITTED cHEC ASH RECOVE'O SY DATE OR I ON T NURIMEI INVOICE R <br />