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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION v �- <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-U20 <br /> IRON-RFFUNDABLE PERMR EXPIRES 1!(EAR FROM BATE ISSUED <br /> (gwputB in TripGntd <br /> APPLICATION IS KEJENY MADE TO THE SAN JOAO.UN COUNTY FOR A PERMIT TO CONSTRICT AND/OR INSTALL THE WONC DESCRIED.THIS APPLICATION IS MADE IN COMPLIANCE WITH a" <br /> JOAOUM COUMY DEVELOPMENT'TITLE CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTYIS <br /> P1)C HEALTH ffNIC <br /> /1Ea,BCVW40NMENTAL HEALTH OPASIOH. <br /> JOB ADORESBMA AMIN1 d'd+ G IL Q:(VyS+ ,U A tJ� cm Si Oct l LOT SIZE <br /> OWNER'S NAMEPAj lb,2 tUI` 72I V4'A.J AODIESS <-)rn <br /> COHActoa <br /> "CONTRACTOR ADDRESS �OOrvvv LCP AIIONE <br /> TTPS OP STINT WORK: NEW INiiAWTION CI RfPA1NAODITI099 DfiTNVCTINL/13 <br /> INT RREPTI,SYSTEM PERMETTED IF FV ELIC SEWER IS AVAILABLE WATHIN 20O FEET OF NUILDINO.I INSIC TOTNI(I NOW MANY <br /> APpM�M S <br /> INSTALLATION WILL SBM FESIDENCE,0 COMMERCIAL❑ OTHER❑ <br /> MUMMER OF UNM I UNITS; I rRNtHI NIP SEDRDOMSNU SM Of PHPLOYESS: <br /> CHARACTER OF SOIL TO A OEPTM OF J FW7_ PITAK)UP SOA CHARACTER- WATER TARE DlPTM T <br /> SEPTIC TAISCANICASE TRAP ❑roq APO CAPUT' NO.COMPANT'MEHTS c- <br /> EKG TREATMENT RANT❑ DISTANCS TO NFA;wT; WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION CI SIZE TYPE OF PUMP SATO OK SEPARATOR(ENCLOSED SYOTEMI C*YTtl 9-1 <br /> A' <br /> F+ <br /> LI=MING NE AND. LEIATN OF LINES� T <br /> � V DIaPAS:E TO NEAPEST+V'MF4��FOLMCATION V6r�PROPERTY UNE <br /> FILTER SID 13 LNOTH LDNDTH OEPTH OINtANCE TO NEAREST;VVEtt IOLRNDATION RoPETRY UNE <br /> MOUNOED YISOTH LENGTH OEIFTH DISTANCE TO NEAREST:WELLFCARAATION PIOP[RTYLINE <br /> SEEPAGE FITSIRE NUMBE'ROIBTANCE TO NEAREST:WETl FOUlNDATR7 FwDPE7OY LINE <br /> SUMPS ❑WIDTItLLNOTH DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE <br /> DISPOSAL PONOS ❑VADTH LEMOTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION P}OPERTY LINE <br /> I HERESY CfKn Y THAT 1 HAVE PREPARED TNN APPLICATION AND THAT THE VJOIR%MLL at DOME IN ACCORDANCE VRTN SAN JOAOL N COUNTY UNINANCES AND STATE IAYVS.AND FOES <br /> ANOIEDLILATONS OF THC SAN JOAOUN COUNTY.HOME 0IM ER OR LICENSED AGENT'S SIGNATURE CUWWMS THE FOLLDANO:'1 CSRTWYTHAT NYMPER011IMMKE OF TE V40M FORYNSCH <br /> THO PHSNR N ISSUED,1 04ALL NOT EMPLOY ANY PERSON IN SUCH A MAMWR AS TO BECOME SI/BJECT TD WOgLMAN'S COMPENSATION LAWS OF CAlo1SAA.'CONTRACTOR'S HMO ON <br /> SUS-CONTRACTINO SIOHATURE CERTIFIES THE FOLLOYMM:'I CHOMP THAT M THE PERFORMANCE OF THE YMM FAM WNICH TNS PERMIT IS ISSUED,1 SHALL EMKUY PERSONS SUBJECT TO <br /> VJOMMVXS COMPENSATION LAWS OF <br /> C�^Lp;�;of"&. T�H/E�APPLIIC}ANT MUST CALL ri HOURS IN ADVANCE PON A,RBOISIIf11 MISPKTMIL COMPLETE ORAYYSO SELOW <br /> SIGNED%� G�==---Lr�6'4' !//'� _ Tnll'_+i/�.{J!t tom}d _ DATE: <br /> U l�/- PLOT PLAN <br /> aDRAW TO SCALET KALE <br /> 1.NAMES OF STREETS OR ROADS NEAICST TO OR BOUGHT THE PROPERTY. +4.LOCATION OF HOUSE SEWAOE ONPOSAL SYBTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPFJRTY.WITH OMFHSIONS AHD NORTH DIRECTION. EXPANSION OF SEWAGE ONPDEAL SYSTEMS. <br /> O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXMING AND PROPOSED STRUCTUFIEu, S. <br /> LOCATION OF WELLS VATNW RROOS OF ONE HUNDRED FIFTY FT.ON <br /> R/CLUDIMO COVEED ALFAS SUCH A8 PATIOS,DRIVEWAYS,AND WAILS. THE PKIPERTY OR AMIDIR B PRRCPERTY. <br /> � +�RNSIPLIJ <br /> sp <br /> 1100 Jew <br /> S �Fcr'oHE7 <br /> f <br /> Awk <br /> t;^ <br /> � .... .. ;..� .. may/ .:..... <br /> Fi A•�A,IG N.�.T <br /> . .... .:. ...1.. . pab <br /> T .. <br /> L: ;t:e��YaErle. . <br /> �' .... .... ... <br /> hl <br /> L.. <br /> . MI4Y 1 # . <br /> • SOMI JCJA4iU141 CpUN1Y <br /> ••AUBL{CMpAYfftS7�VJ�' <br /> ' - EM+IR^NMENTAL.MEAL"M DMS N <br /> FOR DPARWMT USE ONLY _ ff <br /> APPLICATION ACCEPTED BY "'• DATE' <br /> I !� G OATF. L_ / Jr <br /> TAM, RWMP MBFECTIOIN SY 7//' <br /> DATE� lI I��FNAL INSPECTION <br /> ADDITIONAL COMAIE!ll B: <br /> ACCOUNTINO ONLY: NDE F— <br /> >S Co Ig OEO <br /> fMrlw Sv ATE I►BSST NUMMSR NWDICSJ <br /> r l <br /> 1 <br /> Pub.HSEAh$e,•En.rO.174(V96) <br />