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APPLICATION FOR LIOUID WASTE PERMIT <br /> 8AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,904 EAST WEBER AVENUE,STOCKMM,CA 9=1-388 <br /> 12031 498-3420 <br /> F <br /> NON•REFUNDARLE PERMIT EXPIRES 1 YEAR FIIOM DATE ISSUED <br /> m-ampl.0 in lriplint.) <br /> LPPJCATIOH IS HERESY MADE TO THE 9.V7 JOAOUIN COUNTY FAR A PERMIT TO CONSTRUCT ANONR INSTALL THE WORK DERCRISEM THIS APPLICATION 18 MADE IN COMPLIANCE WITH IAN <br /> OA/JUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE 6T AN <br /> OF SAN JOAMAN COUNTY PUBLIC HEALTH SERVICES,ENVIAONU@RAL HEALTH DINWON. <br /> '08 AODRESSfOR AM- �"l ,"/��,.�r ( (1`a t) 1)L...1 0 k/ Cm,_ ( 'T`�,�e T LOT SIZE <br /> WMER'S NAME VAI�J T"I.L.-l.J L�-L.,O AAvIr�- Ti l <br /> ADORES. _ ,1 IYJj1 1". PHONE <br /> :ONTiUCTOq_ I\(.9 11? /L ADDRESS J • ��7� y, y <br /> �— U. i CX � UC/ ATONE—L_7_ 7-�JOJ�J <br /> ILA CONTRACTOR _ADOFFSS 5 <br /> ucr <br /> 'YPf of SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DEATTLCTIDN❑ <br /> 'q SEPTIC SYSTEM PEP,MRTED 1F PU62.IC SEWER 10 AVAILABLE WITHIN IOD FEET OF SUILDINO.I PBIC TISTNI f 1 NOW MANY <br /> APPSaellen <br /> VBTALLATION WRl 60WE RESIDENCE COMMERCIAL❑ 07HER❑ <br /> iLPMER OF LIVING UMTE:�L NIANS@I OF EEDROOM6:__-.j NLAI#01 OF EMPLOYEES: <br /> 'HAAACTFR OF SOIL TO A DEPTH OF 0 FEET;_ rTTISUMP SOIL CHARACTER. WATFA TABLE DEPTH_ _N <br /> EPRC TANKRIRFA"TRAP ❑TYPEIAFG_ CAPACITY_ NO,COMPARTMENTS <br /> KO IREATMENT PANT❑ DISTANCE TO NW1ES7: WELL FOUNDATION PYIPOTTY UNE' <br /> O <br /> LFT STATION❑ SIZE TYPE OF FVMP BR SE <br /> AND OIL (ENCLOSED SYBTFMI 1 <br /> E/LCHNO LIN# E3NO.A LENGTH OF UNE. /u T5 DISTANCE TO NEAREST'WELL "U PJVNOATgNPROPERTY LINE <br /> ILT01 S® ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL _POUNIDATOI PROPERrY LITE <br /> OOUMDED ❑WM)TTI LENBTH _OEPTFI DISTANCE To NEAREST:WELL _FOLINOATION PROPERTYL/E <br /> MADE FIT# ❑DEPTH SLZE NUMBER INSTANCE TO NEAREST:WELL__FOUNDATION PROPERTY LIEN <br /> UM•. ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOVNDATgN PROPERTY UNE <br /> 16P00µPONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_ FOUNDATION PROPORY UNE 6 <br /> MERSEY CERTIFY THAT 1 HAVE PIEPAFEO TMS APPLICATION AND THAT TIN:WOW(WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AN RULES Q <br /> ND FIMULATIONS OF T M SAN JOAO U%W COUNTY.HOME OWNER OR UCEHSEJ AGENT'S SIGNATURE CER'IFIES THE FOLLOWING:'♦CERTIFY THAT M THE PERPONAANCS OF THE WORK FOR VYHW f <br /> HIS P£RIAFT 18 ISSUED,1 SHALL NUT EMPLOY ANY PERSON IN SUCH A MANNHI AS TO SEGO IC SUBJECT TO WOPANAM'■COMPENSATION LAWS OF CAUIFOWRA CONTAACTOI'!MPWQ OR <br /> USCONTRACTING 81DHATURE CERT/HES THE POLLUOWINO:`I CERTIFY THAT IN THE PEIIPDI/AAHCE OF THE WOT/1L FOR UAACN 7111$PERMIT IS ISWED,1 SHAUL EMPLOY P'ER#OLA SUBJECT TO <br /> .'OF MAN'SS C <br /> O <br /> M <br /> PE <br /> NSATION <br /> LAWS OF CALIFORNIA.' THE A"UCMPT MUST CALL 74 HOME IN ADVANCE I"ALL 11EO{ERm WSPEC'W" CON/RETE ORAVRNO BF;/]w <br /> TONED%_LN TIT,*: <br /> Pl—�cO�T PLAN IDRAW 7D SCALE♦SCALE •{e <br /> NAMES OF STREETS OR ROAOS NEAREST TO OR BOUNCING THE PILOPERUY, 4. LOCATION OF HOUSE SEWAGE MSRTSAL SYSTEM OR PROPOSED <br /> OUTVNE OF TILE PRCPERTY,WITH DI AENSION6 AND NORTH DIRECTION. ExrANS10N DP SEWAGE DISPOSAL SYSTEMS, <br /> OIMENBaNEO DLITLBES AND LOCATION OF ALL EXISTING AND PROPOSED STRUC TURFS, 0.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT-ON <br /> INCLUDING COVERED AREAS SUCH A8 PATIOS.DRIVEWAYS,ANO WAI Ke. THE PROPERTY OR ADJOINING PROPERTY. <br /> X60 <br /> a <br /> S <br /> • <br /> , <br /> : <br /> C <br /> FOR DEPAATME347 VIAE ONLY <br /> `PLICATION ACCEPTeo BY GATE: yam.. AREA: <br /> INK,PT OR SUWO WSPECTION BY ! 1_FINAL INSPECTION BY <br /> _ GATE .� <br /> UDRIONAL Cf.MMENT.1 <br /> 3© www,•, 2:✓ 4 v w+.r,.,,..,�... L..ae,.{ '2.��-.�� _ <br /> ACCOUN7INO ON Y: <br /> NDF FACF <br /> FE CODE F O AMOUNT REMI760 NOCK ABH RECOVER BY DATE SR I MIAAIT NUNIEW INVO.�I77CE♦•'���/� <br />