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APPLICATION FOR LIQUID WASTE PERMIT 3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON•REFUROARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (GmplEh M TrIpAEILI) <br /> APPLICATION 18 HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A P6NTIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THrO APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUN COUNTY DEVELOPMENT TITLE. <br /> TTITTLLE.CHAPTER 9.1110.3 AND THE SITANDARDS OF LAN lOAOLW COUNTY PUBLIC HEA1714 SERVICES.ENVIRONMENTAL HEALTH dNSION. <br /> JOB ADOFtISmR APNF /`T�v'L/ �/ CITY G LOT SD.F <br /> E / <br /> OWNER'S NAMCT,/L+l� L;?e2 IC_l d�_5 ADDREse BION! .i Srr�S 7 <br /> CONT}IACTOA ADDAAVS _ LICi �PHONE_Sc�l� <br /> SUBCONTRACTOR ADDRESS LICE PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IM REPAIDADDITION❑ br."oe ON❑ <br /> NO SEPTIC SYSTEM PERV.YTf 40 IF PUBLIC SEWER IS AVARABLE Mv"fK ZOO FEET OF IUTLOOM-1 PELC TiSThl[S/IOW MANY <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMHIERCM OTHER❑ <br /> NUNS@L OF UVINO LDETS: NUMBM OF E[DROOMS: NLWINGR OF 9RPLOYMS'. <br /> CHARACTER OF SOrL TO A OEPW OFFI----3�FEET: Pr7tKW SOS.CRiARACTEFL WATER TA KE DFPIIT <br /> SOMC TANKIORSASE TMP l""!TVMWFO i CAPACITY NO.COMPARTMENTS <br /> PKO TRIATMWT PLAN--TElRES <br /> DISTANCE TO NEAT: WELL F0tMVA7PE <br /> RON � PRORTY UNE <br /> IO <br /> LIFT STATN 0 SIZE TYPE OF P/N4` SAND OIL SEPARAT OR(ENCLOSED SYSTEMI <br /> LEACHING URC ❑� NO.•LENGTH OF LINES OIBTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> FILTER IED DINpNADTH�LENGTH DEPrH,;2-A'r DISTANCE TO NLAMST:4VELLFOTNOATION�PROPERTY LNE <br /> MOUNDED ❑WROTH LENGTH DEPTH INSIANCETO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGS FRS ❑I--I DE"" SQE NUMBER DISTANCE TO NEAREST!WELL FOUNDATION PNDRKrY LINE <br /> BUMPS lJ WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION RIoP UNE <br /> DISPOSAL POND■ ❑wurH LENGTH OMIT DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> 1 HEFtESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WDIK WILL 13E DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AHD STATE LAWS,AND RULES I <br /> AND REGULATIONS OF THE SAN.IOAOLIN COU"".HOME OYAiEROK LICENSED AGENT'S MUATUM CERTIFIES THE FOLLO`NM:'ICEK"FYTRAT INTHE PE370ffA"AA OF THE WORK FUItHIC <br /> WH( <br /> THIS PERATT IS ISSUED.I BHALL HOT EMPLOY ANY PERSON DI BITCH A MANNER AS TO BECOME KMJECT TO WD W MNTS COMPENSATK)N LAWIF OF CALIFORNIA.- CONTRACTOR'S"MUMOK <br /> SUB-CONTRACTNO SIGNATURE CERITFE'B THE FOLLOWING_'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR 1NiK:H THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS BUS.KCT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA-' THE APPLICANT`MUST CALL 14 HOURS IN ADVANCE FOR ALL REOtM1ED INSPMTWNS. COMPLETE DRAWING BELOW. <br /> pT�— YI- <br /> MONEO K Trm T7z DATE: <br /> HAT RAN(DRAW TO BCALF1 SCALA TO -5 <br /> 1, NAMES OF STREETS OR 11M) <br /> ROAOB NEAREST TO OR S0INO THE PROPERTY- A, WCAT)DN OF NOUN SEWAGE EAWDE/LL SYSTEM OR PROPOSED 1 j <br /> 7. OVTLPW OF THE PROPERTY,WITH DIMENSIONS AND NORTH UIRE17 ION. FXFANSION OF SEWAGE DISPOSAL SYSTFMS. '+. I <br /> O, DNAENMh%ll OUTLNEB ANO LOCATION OF ALL EXISTSNI AND PROPOSED STHUCTURE/, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HMDRED FILTY FT.ON J <br /> .L....COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ARO WALKS. THE PROPERTY OR ADJOININAR PROPEIITY. <br /> .. ... ... AAAA ... AAAA.. , <br /> • <br /> . •AAAA.. : <br /> .. ... .. .. ..;......_....AAAA.. .......... <br /> AAAA.. ....�... ..,............. <br /> AAAAAAAA..... AAAA ........ <br /> �.. . AA <br /> AAAA <br /> ..:. .. AAAA AAAA ...... .. ..... AAAA... .. .. AA <br /> AAAA. . <br /> AAAA.. .. .. .... <br /> ... ..... AAAA .. .,. . .. G � <br /> u <br /> R' <br /> ._... 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' <br /> ........... .� `. �.. ..:...........................:... _.........._AAAA.....i............ <br /> AAAA. <br /> FOR DmAPTMENT USE ONLY <br /> ,-t <br /> APPIICAipN ACCEPTED BY DATE: AREA: <br /> TANK,PIT OR BUMP NSPECT)ON BY DATE I ! FINAL INSPECTION 15DATE r I A 7 <br /> A. <br /> All-I Aa— <br /> ADDITIONAL COMMENTS: '� <br /> I ' l <br /> ACCOVNTING ATO# FAC# <br /> PE CODE jfffw"4�t�WfTFtEMIITFD CTRL AIN RECEIVED By DATE ER/PER/IT NUAAEI NvaCE! <br /> Pub.Hmn Ser -6nviro.174(3(96) <br />