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AFPtiCATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O.BOX 368,304 EAST VIIMBER AVENUE,STOCKTON,CA%=I- 8 <br /> {2091 485-3420 <br /> NOA•REFMNUAKE PERMIT EXPrRES I YEAR FROM"TE 184Uf0 <br /> ICfmpiBtf IA Tripikauf <br /> APPLICATION III HEREBY MADE TO THE SAN JOAOtW COUNTY FOR A PER UfT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED. THIS APTLCATXM IS MADE IN COMPUANCE VRTH BAH <br /> JOADUN COUNTY MMOPMUff RETIE,CHAPT919.1110.3 AND THE STANDARDS OF SAN JOAOM COUNTY N10UC HEALTH SERVICES, M <br /> ENvIRoNMEXrAL HMTH OBIJN. <br /> JOB MHSRESSIOF1 ARNP c>i �rCrrr 7J LOT saE <br /> OWNER'S NAME I /' C Aoon.. n J6 <br /> CONTRACTOR • iGJ ADOW" �4/{11� ucr PRaNE <br /> BUB CONTRACTOR ADDRESS LMS PHONE <br /> TYPE OF$gym WORK! NEW INSTALLAWON❑ IISNIVAppTON DMTRLwntm❑ <br /> IND SEPTIC SYSTEM PEFWrrED IF PUBLIC SEWER RS AVARABLE VWNIN 400 FEET OF BUKD WO,I Pom TEaTMI I 1 MDW laANT <br /> ApgPBSar <br /> INSTALLATION WILL oarm RESIDENCE COMMERCIAL❑ OTHER E3MUMBaDr OP LMND IMiRTf:�NUMf61/// OP BSDROOMf: �� NUSaSELT OF BAPIOYBS: <br /> CHARACTER OF&OIL TO A DEPTH OF 4 FEET: PIT/BIN 8 LLC RACIER: )) WATER TABLE M Ttt <br /> SEPTIC TANKMPEASE TRW ❑TYPEA4FG + �` APACRY I?_GU r�C1 No.COWAR7MENTO <br /> ►ICO TRFICIMIXT►LANT❑INSTANCE TO NEAREST: WELL. 4' FOUNDATION PPgPC9UTY UNE 11 ` <br /> UFTSTATION❑ SIM TYPE OF P°l/AP SNA OIL SEPARATOR IENCLOSED SYM-W /V <br /> LEACNNO UNE ❑ NO.a LENGTH OF LINER DISTANCE TO NEAREST:WELL FrARMTIDN PROPERTY LNIE. <br /> FILTBL BID, 0 WIbTH LEMTN__DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERrV UNE' <br /> MOUNDED ❑WIDTH LENSTH �DEPTN DMITANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SE'mAGE PITS Q DEPTH SITE _NUMBER DISTANCE 70 NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS ❑WIOTN UNWH DEDISTANCE STANCE TO NEAREST:WELL FOUNDATION PMPERfYLSE <br /> WSPOIAL PONDS Q WIDTH LENGTH Ok PTH DISTANCE TO NEAREST:WELL FOUNDATION PFlD ERTY LME <br /> 1 HERESY CERTIFY THAT I HAVE PMPMED TNRI APRICATIOH AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY OMNA14CES AND STATE LAWS,AND FUZES <br /> AND REOULATIONSOFTHEGAN JOAGUWCOUNTY.NOME OMMEROR UCENEED AOENT'A BIDNATURECERTIFIESTKPOILLO ANO:'ICt7RFY7HATINTYE PNO'OH4ANCEOFTHEWOKFORWHICH <br /> TMS PERT K tSf" I SHALL NOT EMPLOY ANY P01BON W SUCH A MANNER'.AS TO BECOME SUBJECT TO WOIF:MAN'S COAf4NSAT014 LAWS OF CALIFORNIA.' CONTMCTOWS HIRING OR <br /> SUB-CONTRACTSKI BBNATURI CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERORMANCE OF THE WORK FOR WIBCH TMS PERMIT IB ISSUED,I S/W1 EMPLOY PERSORIS WIVECT TO C <br /> WORKMAN'S COMPENSATION LAWS OF CALIFO ITHE APP IC ANT MUST CALL 34 HOURS IN ADVANCE FOA AL.L REODU*FJD INSMMklb.COMPLETE DMN71G BMW. 3 <br /> 810MO X i T7TSd. �C7L:��l,r DATE: F <br /> T PLAN MRAW TO SCAII;I&CA.'.E 'to <br /> I.NAMES OF STREETS 04 RDADS NEATEST TO OR SOLMONNO THE PROPERTY. 4,LOCATMW OF HOUSE SEWAGE DISPOSAL SYSTEM OR FROM <br /> SED <br /> ,OWUHE OF THE PROPERTY.WAN OIMENSIONS AIA NORTH OtRECT}ON. UD(PANBgSP <br /> N Of BEWARE DISPOSAL 9YSTTM4 <br /> 1.DIMENWONED OUTLINES AND LOCATION OF ALl EXUT BEO STRUCTURES. E.LOCATION OF WH WELLS ITM RA"OF ONE HUMORED FIFTY FT.ON <br /> INCLUOUTD COVERED AREAS SUCH AS PATOe,DNVEWaOI D WALRB. THE PROP9QY OR ADJOINING PROPERTY. <br /> ._ <br /> LkLLa � DEC'.Lt 1395 <br /> ------------ <br /> - <br /> FOR OEPARTMIXT USE ONLY 'AT <br /> APPUCAT"ACCEPTED 9Y _ OI17F: ATEA: 7-I <br /> TAMC,PTT DR SUMP MSPECTION BY DATE ! t FINAL INSPECTION BY DATE l 2^I 2'0I <br /> ATNIfrgNAl COMMENTS: 'ill v •-"-I <br /> ACCOUNTm.ON Aqt TACT <br /> re COOS AMOUNT RFTBrTis) B ASH I%PCUVCD BY DATE an f PwfAT NU~ kN010E0 <br /> Alp I3 b <br /> S <br /> 03 ,\3 <br />