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4a�z3� <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST VYESER AVENUE STOCKTON, CA 9SMI-388 <br /> (209) 48'-3420 <br /> ON•REfUNDABLE PERMIT EI FIRES 1 YEAR FROM DATE ISSUED <br /> IC+tipl.0 YR Triplbats) <br /> AMJCATION IS HErEHY MADE TO THE SAN JOAGU N COUNTY FOR A PERMFT TO CONSTRUCT ANOMS INCTALL THE WOR(DESCRIBED. TWO APPLICATION I@ MADE IN COMPJANCE WTTH SAN <br /> JOAOIXN COUNTY DEVELOPMENT TITLE.CHAPTfJt 0.1110.3 AND THE STANDARDS OF SAN AOUIN COUNTY PVOLK:HEALTN SERIACES.ENVIRONMENTAL HEALTH DIVISION. <br /> (GL/ �` <br /> JDB ADDIIESSlOR APN• <br /> ' CRE'�!1-,i �"� / LOT 812E rn^l' <br /> OWNER'S NAME aS PHONE A <br /> f ' ? /4 <br /> CONTRACTORIlziz - ADDRESS �- LICE/,3 -/ <br /> BLPE CONTRACTOR ADDRESS UCit PHONE <br /> TY►I OF 9EPTC WORK: NEW INSTALLATION RIPAIVADOITION ❑ D"TRUCTION❑ <br /> IND SEPTIC SYSTEM PERMRTED IF PUBtIC SEWER IS AVIULANLE WITHIN 200 FEET OF RUILDMO.I PLIC MTN)I I HOW MANY <br /> APFSe�Sew/ <br /> IPNITALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER❑ <br /> NUMBER OF LIVING LAITM NLNJM§nOP E WOOMS: NL1NP8[Rt OF YNPLOYIFA: r <br /> CHARACTER OF SOIL TO A DEPTH OFF33 FF/EET: PrFlOWP SOIL CHARACTER: &ATER TABU DEPTH <br /> SEPTIC TANKIOPWASE TRAP Q)'TYf swc CAPACITY D NO.COMPARTMENTS <br /> PRO TRlATMlNT PLANT❑ INSTANCE TO WA1181T: WELL�,�e r-OUNOATION P}10PERrY UNE <br /> t8°T STATION❑ 817 TYPE OF PUMP SAND OIL SEPARATOR KNICLOWD EM) �` 1 1<96©6 <br /> LFACNNG UNI NO.i LENGTH OF L1NEa� 71-5 TMTANC[TO NEAREST:WELLL r FOUNDATION PROPNfTY VNE <br /> RtTDI BED ❑WIDTH LENGTH OEPrH1 DISTANCE TO NEPIEST:WELL FOUNDATION PROPERTY LINE N <br /> MOUNDED ❑WIDTHI LENGTH DEPrH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> ■MAO!PITS ❑DEPTH ®ZE NUMMR 019TANCF TO NEAREST:WELL FOUNOATION PROPERTY UNE 00 <br /> SUN" ❑WIDTH LENO'TH DEPTH DISTANCE TO NEAREST:WEIL FOUNDATION PROPERTY UW ! <br /> DISPOSAL PONDS ❑WIOTH LENGTH I DEPTH dBTANC'f TO NEAREST:WELL FOUNDATION PROPERTY , <br /> LINE W <br /> I HIREBY CERTIPY THAT I HAVE PMEPARED TWO APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUtN COUNTY ORDINANCE!AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE RAN JOAOUNCOUNTY.HOME OWNER OR UCENSIM AGENT'S WONATLRIE CEITIFE9 THE FOLLOWING:'I CERTIFY THAT N rWF PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A9 TO BECOME SU9JECT TO WORLMAN'S COMMOAT10N LAWS OF CALIFOPMA.' CONTRACTOR'S HIRING OR <br /> SUBCONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PnWrr I9 ISSUED.I ONALI•EMPLOY PMOON8 SUBJECT TO <br /> WOFWMAN'8 COMPENSATION LAWS Of W <br /> FOIIA.' TR!APPLICANTFOR ALL MUST CALL 24 HOURS IN ADVANCB FOALL R/OLMIED MSMCTIONS. COMPLETE ORAWNO MOW. , <br /> SIGNED X_,-- 71TIE:2QL22 DATE: fi <br /> PLOT N IDRAW T13 SCALF1 SCALE ,1. <br /> 1. NAMES OF 97REETS OR ROADS WARM TO OR ROUNDING THE PROPERTY. 1, LOCATION OF HOUSE 8[WAGE DISPO104'. OII PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH OM"NMR9 AND NORTH DPECTKM. EXPANSION OF BEWAOE DISPOSAL 9YSTEM8. <br /> 3. DIMENSIONED OUTLOI99 AND LOCATION OF ALL EXICTNG AND PROPOSED 9TRUCTUREB, 8. LOCATION OF WELLS WTMN RAMUB OF ONE HUNDRED ED FWTV FT.ON <br /> INCLUDIENI COVERED AREA/GUCH AS PATIOS,Dl9VEWAY9.AND WAULS. THE PROPERTY OR AOJONINO PROPERTY. <br /> .. .... <br /> I <br /> ............. <br /> .. .., .... .•. .... .. .. ..... <br /> •! .. U.(.`... . . <br /> W' <br /> pa <br /> 44 , <br /> ---.. <br /> 4 <br /> - <br /> I . <br /> A eco ..... . . .: �. <br /> ' <br /> • <br /> r <br /> C-0 VIA I <br /> Gt.Gn �uuhk�5f �fac,� <br /> As t3eFcra .,.z'': ..:. MAY 9 11M, <br /> .... ......._.......... V 1S'LCl r3L47lioR�i :�rll 1[ •: .. ... .. Yllh'.'i'§•^^.''I <br />