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"O �, moo yy2 <br /> r APPLICATION FOR LIQUID WASTE PERMIT' <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SIMM- 88 <br /> (209( 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Tripileetel f <br /> APPLICATION 18 HEREBY MADE TO THE BAN I0AOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oft INSTALL THE WORL DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CH/AFTER 9-11100.3 AND THE STANDARDS OFF SA/N�"AQUIIN/C�OUNTTYY PUBLIC HEALTH SERVICES,EN�VJIRONMENTAL HEALTH DIVISION. j n <br /> JOB ADDRESSOR APNF /JC)�P I /f �(///�>� /'//f//'J�eG�'jL�J ' '/�!/-f/'��/l�G���CT/ L6IZEC <br /> OWNER'SNAME. �/r�L G��.L����F' J /.-!/�ry //AOOPE65 /J PFJ U Zl ,(/�yyI ,/�� / /JQ ��I•�/A1p 1 'J r 7Ei� 372, <br /> /l✓:fn < BL r<L7 <br /> CONTRACTOR 7�.�/c �c`1.t117`. Li(•%%tet'•7iwne6s <br /> F }IPHONE <br />- sue coNTRAc1oR <br /> ADDRESS uCF II PRONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPARDAONTION ❑ DESTRUCTION <br /> IRO SEPtIO SYSTEM PERMITTED U PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) '— PEgC TESTI 1 1 HOW MART <br /> [:ApP%adccn B <br /> INSTALLATION WILL SERVE: RESIDENCE 13 COMMERCIAL OTHER ❑ _ .,! <br /> NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �+ <br /> CHARACTER Of SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH '� C <br /> SEPTIC TANIUMEASE TRAP ❑TYPERAFO CAPACITY W.COMPARTMENTS I <br /> MG TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION - PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF{PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMit U <br /> LEACHING UNE NO.B LENGTH OF UNEs q /0 DISTANCE TO NEAREST:WELL FOUNOATN)N PROPERTY LINE <br /> FILTER BW 13 WIDTH LENGTH DEPTH DISTANCE TO HEADIEST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ME <br /> i <br /> SUMPS 11 WIDTH LENGTH DEPTH DISTANCE TO NEATEST:WELLFOUNDATION PROPEITTY UNE <br /> DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH BAN JOAOUM COUNT`/ORDINANCES AND STATE LAWS,AND RULE; L_ <br /> ANO REGULATIONS OF THE BAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AGENTS SIGNATURE CERTIRE8 THE FOLLOWING:-1 CIRF IFYTHAT IN THE PERFORMANCE OF TMWOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO W WKMAN'8 COMPENSATION LAWS OF CALIFORNIA.-,CONTRACTOR'S HIRING OR <br /> SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE W OM FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATIONLAWSOF CALIFORNIA: THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOIL ALLREGUNEU INSFIONS <br /> ECT . COMPLETE GRAMM BELOW, <br /> SIGNED X TITLE: DATE: /' <br /> P.OT PLAN(DRAW TO SCALE?SCALE 'lP <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL'SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WMXB. THE PROPERTY OR ADJOINING PROPERTY. <br /> ( �Y f) <br /> .. ... .� � _� �� of <br /> OF <br /> _ C <br /> �C✓ r, r <br /> P <br /> 4. <br /> I `ry . <br /> 1 ?frrfr a <br /> Z. d7 y-. t % I �.' Lt 1 PAYMEN ^' <br /> RECEI . s <br />