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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> R AVENUE. STOCKTON• CA 952029 �NNED <br /> (209) 468-3420 <br /> UNDABIE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IC$APlato IA TfiSrUBNTNI <br /> AP'LIC AT ION 19 off MBY MADE TO IME WAN JOAGUN COUNTY FOR A PERMIT TO CO N$1 PLICI ANO/OR INST AI I TIIE WOR,OF SC ItlAFO TMD APfEICATION 18 MAGE 1N f•OMPZIANCE VVAN BAN <br /> JOAOUIN COUNTY DMLOPMENT TITLL CHAPTER 9.1110.3 AND THE WTAIN)AROW OF RAN JOAOUIN COUNTY PUBLIC HEALTH PERV1/C[R.fw'gnONMENITTAAL Hf AtTH[NNWION. <br /> /0A ADLIRESBAGR APNE S^ ,cv/)SL" CITY 12 11 L'j I..,our L2 <br /> OWNER-*NAME( (/ ADORESP �• ' PHONE <br /> CONTRACTOR 2• ADWIEfR �y�IL� •C'�1�L':/7�'•: P�LICI PHONE 47 <br /> RUB CONTRACTOR ADDRF[,S <br /> -tic's f4IONf <br /> TYPEM SEPTIC WORK NEW INSTALLATION❑ AFTAIRIAOOITION OFSTRUCTION❑ <br /> II/0 RFPTIT•SYRIFM IERMITTPD R PUBLIC RFWFR IB AVAIIAKI I N4IHIN 700 FEET OF Fl11t DINO.I ►OIC TI$11.1 I 1 NOW MANY <br /> ASp$IrSnn/ <br /> INSTAILADOM WILL GUM, RfBIORNC* COMMERCIAL ❑ Olmp 11M <br /> NUNNFA Of LNO UNITS MIANAER\\\OF WO7ROOMS WAABO[Of pNROYCF8 <br /> CI/AMCTFR OF ROPE TO A DEPTH OF 7 FEET D1 moueARACTER WATER TABLE DEPTH <br /> SEPTIC TANKXMASI TRA--P ❑TYPE/LIFG .CA/< 6OI<' CHCAP,M71Y--]ALL NO.CO.PARTM/N[a Z-' <br /> PEO TRFATMFNT PUNT C DISTANCE TO NLARIIT WELL 2'ay FOUNOATKIN PROITITTY LINT <br /> IRT STATION❑ 0,-f TYPE OF PIMP 8AND OIL.STPARATOR IFNCIORFO RYSTFPAI <br /> If ACNNO UNE A NO,A LITWI 111 OF LINER C':! —4rIF OIFT ANCI 10 NT AAF RI-W[1L `-1 FOUNDATION•`��--+ PROPERTY LINE <br /> FILTFA SFD ❑VNOTII LENGTH DEPTH DISTANCE TO NF.AFFBT�WILL FOUNDATION PROPTATY UNE <br /> MOLINOfD ❑WIDTH LENGTH DEPTH [WIfTAPCF TO HEAFQRT:WELL FOUNDATION POPERTY UNF <br /> SFIPAOF PRTS ❑DEPTH BRE NUM8FR DIBTANCF TO NEAREST:WELL FOUNOATTON PROPERTY I.INE <br /> RL/A►S ❑M'IDT If 12NOTH DEPTH DISTANCE TO NEARCRT WELL FOUNDATION PROPERTY I1NF <br /> d$POMl PONDS ❑WIDE 11 IFNOTII DEPTH DISTANCE TO NF.AMRT:WFLI FOUNDATION PIOPFRTY LINE <br /> I HERFAY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND T1/AT THE WORK WILL AE DONE IN ACCOROAPWf WITH ULAN JOAOUIN COIINTF ORDINANCES AND STATE LAW&AND ISAER <br /> AND REGULATIONS Of THE SAN JOAOUN COUNTY.HOME DWNER OR LICENSED AOENT'R WONATURF CERTIFK N THE FOLLOVNNO '1 CFFrnrY THAT INTNf PERFORMANCE OF"WOPS[FOAWVLIICII <br /> TMS PERMIT IB ISR[KD.I SNAIL NOT EMPLOY ANY PERSON M VJCH A MANNER AS TO BECOME SURJECT TO WOWMAN•S COMPFNSATION LAWS OF CALIFORNIA• CONTRACTOR-0 HII$NO OR <br /> -R.T CONTRACTING AN[NATUIIF CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THF..PERFORMANCE OF TNF NR+RK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERAONS RUBJECT TO <br /> WORKMAN'S COMPENSATION IAW8 OF C RNIA.' THE AP94MANT MUST CALL M HOURS IN ADVANCE FOR ALL PROUIPRID IMSPFCTIONS. COMPLETE DRAWING RFLOW <br /> .,T /') <br /> � 0/L7 (//�RIONEO, r t I k `�! TITIf L4/�j' •.n DATE. ✓- I 'PI07PIAN RIRAW TO RC At iI SC At <br /> I NAMES OF RTMET 8 OR ROADS NF ARE ST TO 0R SOUNDING THE POPERI Y, A. LOCATION Of HOUSE.BEWAOE DISPOSAL.SYSTEM OR FMMSFD <br /> 7OUTIWJf OF TRK PLDFERTY,WRH DIMfHRION$AND SORT/1 DIMCTION. EXPANSION OF FEWAOf DISPOSAL BYBTTMS <br /> JNE <br /> . OIMFNMN[O OUTLI $AND tOCAT1ON OF ALL EXISTING ANO POP)RFD 91 OLICTUMS, 16 1 OCATION OF WELLS WITHIN RADIUS Of OW HUNDMD FRTY FT.off <br /> INCLUDING COVTMFD AAFAS SUCH A8 PATIOS.OfWWWAYS,AND WALI[F. THE PROPERTY OR ADJOINING PROFTRTY <br /> N <br /> v � <br /> r'A04:int S <br /> �.�. ,.rte, -1IK • <br /> 1 <br /> E. <br /> 31 <br /> 20�Ll <br /> SAN JOAUUIN(;,:-UNTY <br /> F-UI3(JC HEALTH SORVI ;Ui <br /> EWU<)NA1ENT'AL HEALTH tJ1YLf.-. <br /> FOR OEPAP.TMFNT IME ONLY <br /> AI'RICATION ACCEPTED BY ` v v`I� - DATE: -/F~ `•[!f AIEA•� <br /> TANK.PET OR VJMP INSPECTION BY DATE FINAL INSPECTION RY 'WITE� <br /> ._. 1 - P f ! /.. - <br />