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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA&5201388 <br /> 1209)488-3420 <br /> NOU-REFUNDABLK PERMIT EXPIRES 1 YEAS fog DATE MUD <br /> (CBNPMa In TrrllnUl <br /> I APPLICATION IS HEREBY MADE TO THE BAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORD DESCAIBFD.TMS APPUCATIDN IS MADE W COMPLIANCE WITH SAN <br /> i JOAOUIN COUNTY OE'VELOFMETT TITLE,CHAPTER 9-1110,3 AND THE RrANOAAm OF SNI JOAOUM CO NTY PUBLIC HEALTN SERIRCEB,ENVNIOSMtNTAL HEALTH DM"N. <br /> i Jas ADOREssroa IAN/ (,3 U Q g L,,, Tr f P /�{C� Cm —1 _' Lor e1n D <br /> OWNER'S HAME��)211 �• �j�M�'iCZ ADWIE88_._.� 'R rm'. � A%x—, .__ PHO'AE O Q3 8—O <br /> I CONTRACTOR AOOMGS V UC/ _PHONE <br /> DUB CONTRACTOR ADORESB OCR PHONE <br /> I <br /> I TYPE OF SB'TIC WOK: NEW INSTALLATION IISPAIIUAODITNHI❑ P"TBUCTION❑ <br /> I <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER M AVAILABLE WRHIN AOa FEET OF SUI DING.) P/IL TESTG't S NOW MANr <br /> I INSTALLATION WILL So"i RESgENC`za� COMMERCIAL 11 OTHER❑ <br /> RUMBA OF LMNO UMTS:--L—MALIBBI'w BEDROOMS: NUMBER OF BAPLOYM:_.�� <br /> CHARACTER OF DOLL TO A DEPTH OF,FEET:_, _ _ PTIBUEEP BOR.CNCAMCTEP m p WATER TABLE LEDCE� MS �Z� <br /> 'CM TANR/01EASE TRAP IF TYPEAAF6, 1�J�y) Vj�//� <br /> PRO TREATNFENT PANT❑ DISTANCE TO NEMYT; WELL FOUMAT10N FROPERTrY UNE <br /> LST STATION❑ 812E TYPE OF PI_W SAND OR SEPARATOR(ENCLOSED SYSTEM) <br /> I LFACNNO UNE NO.B LENGTH OF UNTIE _J DISTANCE TO NEAREST: FpUNDAMN PROPERTY UNE V— <br /> Acret m Q wwH LENGTH _DEPTH DISTANCE TO NFAREBT:WELL Fn NIDATION PROPERTY LkNf c� <br /> MOUNDED ❑WIDTH LENOTH _DEPTH DISTANCE TO NEAREST:V UJ. _FOUNDATfON PROPERTY UNE <br /> /9DAOS INTO ❑DEPTH am NUMBER_DISTANCE TO NEAREST:WELL , FOVNOAIION PROPERTY UNE <br /> SUNS �MRDTH--� LENGTH !)FpTH_ �deTANCE TO NEARER:WETl1�v FOUNOATNYM PROPERTY lJ1k <br /> ` DISPOSAL PONDS Q WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I <br /> IIE <br /> 1 IIEEY CERTIFY THAT I HAVE PREPARED THIS PLIC <br /> S APATION AND THAT 7Hf.WORK WILL BE DONE IN ACCORDANCE Y'ITTN BAN JOAWN COUNTY ORDINANCES AND STATE LAWS,AND USAED <br /> AHOIK*LATIONB Of THE SAN JOAOUN COUNTY.HOME OL4HERORLICENSECAOEMT'S SIGNATURE CEITTBIES THEFOLLOVANO:-ICMTWYTRAT N THE PEMOMAMIOE OF THE WORK FORWWH "1 <br /> TMS PEF"t IS 116 D,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WOPKMAN'R COMPENSATION LAWS Of CM/FOPI NI.A.' CONTRACTOR'S HIRING OR <br /> BU6CON=M8 BIONATUIIE CERTIFIES THE FOLLOWNHO:'1 CERTIFY THAT M YIIE PERFORMANCE OF THE WOM FOR WHICH THAI 000,11IT IS ISMID.1 SHALL EMPLOY PERSONS K161ECT TO <br /> WORKMAN'S COMPENSATION LAVE OF CALIFOF" THE APFUCAM MUST CAU.24 HOUPW IN ADVANCS FOR ALL AEOIN16D NSP'SCTIONS.COMPLETE DRAWING BELOW. <br /> �) « ^ <br /> � SNIPED R TrtiE: l D/���YT � DATE: 6 lC <br /> I <br /> PLOT N MRAW TO SCALE)SC'F 'De <br /> 1,NAMES OF STREETS OR ROA08 NEAREST TO OR BOUNDING THE PROPERTY, 4.LOCATION OF MOUSE SEWA01 DISPOSAL SYSTEM OR P"OPOWD <br /> n <br /> � 2.OUTLINE OF THE PROPERTY.YVl'TH DIMENSIONS AND NORTH DIRECTION. FJ(PANSgN OF SlYYAOC OfBPOB.AL SYSTEMA Ip <br /> ]. 0IMENSgNSD OUTLINES AND LOCATION OF ALL 1%ISTING ALIO PROPOSED STRUCTURES. S.LOCATION OF WELLS WTrHIN PAD"OF ONE NUNOIID PIPrY FT.ON <br /> V CUIOBIO CoVET®AREAS SUCH AS PATIOS ORRVEWAYSI MID WALKS. THE PNDPHUY OR AWOINM FROPERTY. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALK$, THE PROPERTY OR ADJOI PAOPERI <br /> at <br /> s <br /> 4 <br /> ' <br /> 1 7- <br /> c � <br /> --_ -_ - -- - POIIOrMTS1ESIT LIN OEILY a�,N00 40A.If( <br /> APPLICATION ACCEPTED BY GATE: ATEA:•Z/O L <br /> TAN(,PIT OR SUMP INSPECTION BY DATE f 1 FINAL..VECTION SY bATI , � <br /> tft <br /> AOOITXAM C MMENTB: <br /> A"(',u NTIND ONLY'. ARN <br /> nE CODE FEE INFO AMOUNT REMITTED NEC (CASH AEC;:rD BY DATE M 1I'lSAi NRMR INV OM:T I 1 <br /> CODE <br /> l `ty �� SO <br />