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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JQAQUIN COUNTY PUBLIC HEALTH SERVICES l <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA OSMJ-38�, <br /> 3209!488.3428 <br /> NON-BEFdNDA IE MMIT EXPIRE$I YFAX FROM DATE MOM <br /> ICRwp)fTA Y Trip14RTA) <br /> APPLICATION IS HFREBV MARIE TO THE BAN JO—AOOIN COUNTY FOA A PERMIT TO CONSTRUCT ANOXIA INSTALL THE WORK DESCRIBED.THIS APPLICATION Is MADE M COLAIMIA CE WTTN SAN <br /> JOAOUIN COUNTY LIEVELOPMENT TITLE.CHAPTER <br /> 9-1110.3 AND THE STANDARDS Of SAN JOAMAN COUNTY PUBLIC HEALTH SERWES,ENNADMSPETTAL HEALTH OMSYON. <br /> JOB ADDREGS/DR AP1"N�O__-��--��yp/Il �J( �•/� /a� {nye" LOT 612E <br /> OWNIEA•B NAME (-5 NF1'//y ���iy/V ADDRESS TJ' <br /> CONTRACTOR A4 //7� z--/� Zg ADgE66 �y� Tj�c�E��' 'moi �f? LICE v'}'�j pZ�Ffq/E/j_•�/��7' <br /> SUS CONTRACTOR ADDREBB UCS RIIGNIF <br /> TYPE OF SEPTIC WORK: NEW NSTALLATIOM❑ 011PAURIATIOITION K DOTRUCTRON 0 <br /> M SEPTIC SYSTEM PERMITTED TO PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF 6LRLDN0.1 AM MANY <br /> APSSrSOR J <br /> SPSTALLATION WILL AWWF: RESIDENCE Tkf COMMERCIAL❑ OTHER <br /> NUA1061 OF UMNO UMTS: -57 <br /> _NUMSBL AF SmS�NN�OOMs: '• NU ASM Of AMKOYRN' <br /> CHARACTER OF%DTL TO A DEPTH OF T FEET:_..,e'( PITPSUMP SOIL CHARACTER: ATTABDFPTIL <br /> 1K.A <br /> SEPTIC TANK10SS TRW 0 TVT£6AFOy CAPACITY_WlR LE NO.COMPARTMENTS <br /> PKO 77LEAWANT►CANT Q DISTANCE TO NEAREST' WALL FOUNDATION PROPERTY LINE <br /> 1kc';eFL i"7"��ATT,QIIGM❑ SIZE TYPE OF MMP SAND OIL SEPARATOR EiNCLOSED SYSTEM <br /> LLACfiNS UNJ(41 EDI MO.S LENGTH OF LM v-/-=-g a eoo�r DISTANCE TO HEAPIE"!WQL fOUNEEAF10F1/e` P110PERTY 1N!Z�42-1 <br /> FtLTEt REO ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WEU. FOUNDATION PROPERTY LUNG <br /> WIDTH_ <br /> MOUNDED ❑ LVW7H�- _DEPTH DISTANCE TO NEAREST:WELL _FDUNDATgN PROPERTY LNPF <br /> &MADE NTS IJ DEPTH SIZE �NUMBER DISTANCE TO NEAREST:WELL--FOUNDATION PROPERTY LINE <br /> SLPAM Q WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL__,FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS CJ WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_ PDUMOATDN PROPERTY LIM <br /> I HEREBY CERTIFY THAT 1 HAVE PTEPAPEO THIS APPLICATION AND THAT THt WOM WILL SE DONE M ACCORDANCE MTH SAN JOAGUIN COUNTY O/OINANCEs AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOADIAN COUNTY.HOW OWNER OR LICENSED AGENT'S NMATtME CERTIFIES THE FCLLOVANO:'1 CEKr"THAT M THE F[RIFORIAANCE OF TOE WORK fO WHICH <br /> THIS PER"IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO 6ECOME SUBJECT TO WOrAAMAN'S COMPENSATION LAWS OF CALIFORIPA.' CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLOWMO:'I CERTNY THAT N;TIE PERPOHAANCE OF THE VMW FOR V410CH THIS PEP"T IS Mstrw,I SMALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CAUFOIMA.'TIRE APPLICANT MUST CAL`,91 HOW IN ADVANCE MJA ALL REOUNIRD IMSPSCM116. COMPLETE OMW NIG*[LOW, <br /> SMNED K__ C:yi: TI'1J:: DATL•CL/I-/a�L ,�'`+J <br /> PLOT PLAN(DRAW TO SCAM SCA(E •Ie .J� ) <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOVNOINO THE PROPERTY. M.LOCATION OF HOUSE SEWAGE DISMSAL SYSTEM OR PRLOPbSEO �I <br /> 2.OUTCOME Of THE PROPERTY.TMTH DIMENSRON6 AND NORTH DNECTON. EXPANSION RIF SEWAGE DISPOSAL BYSTEMH, <br /> J.DIMENSIONED OUTUNES AHO LOCATION OF ALL EYISTOM AND PROPOSED STRUCTURES. i.LOCATION OF WELLS WTHW RADIUS Of ONE HUNDRED f6TY FT.ON <br /> INCLUM4 COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.ANO WMXR. THE PROPFITty OR ADJOIN"POMP EY". <br /> qp'm <br /> 4. <br /> �:. <br /> .. ;. .,. .., 'RECEft� p _.. . . <br /> i . JAN <br /> 8 200 <br /> I . . _ .. SAN„WgtHRrCO(1N' ' <br /> �I <br /> PUBLIC <br /> IV <br /> L�YVl9�rhFii;1'g j,Z n,;�TrylcNlh <br /> �4 LYR!9Ta'd�.. <br /> FOA W1AR7MpT VSE ONLY <br /> APPLICATION ACCEPTED BY DATE: /_/ _O I AREA:�� <br /> TANK,PT OR 6UM.P WSPECT BY DATE I I FINAL INSPECTION SY <br /> ADDRIONAL COMMENTS: <br /> ACCTiUNTNO ONLY: MDI FACE <br /> ^'ECOOE FEE INFO AMOUNT%"ITSD HEC ASH AfCOVED SY DATE M 1 RtlMIST IN%PAB R DICE IT <br />