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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBtiC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.EIOX 388.304 EAST WEaE:R AV MF_STOG7C R CA 55201388 <br /> (2091468-3420 <br /> 11ON-R FUN BLE PERMIT EXPIRES 1 YEAR FROM DATE ISOUEP <br /> APRICATtON t8 HETIEBY MACE YO THE SAN JOAOURJ II`A glass Ill TripRoSbl <br /> COUNTY FOR A PERMIT TO CONSTRUCT AND)OR INSTALL THE WOO(DEBCAVED,THIS APPLICATION IS".ME H4 COMPLIANCE WRH SAN <br /> JOAQUIN COUNTY OEVELOPMENNT TITLE,CHAPTER 8-1110.3 AND <br /> /yTHE STANOARDS OF SAN JOADUIN CO/�UNTY @M <br /> PUBUC HEALTH SERVICES, ROFMRJPTAL HEALTH DIVISION, <br /> Jof ADMESWOR APLvf_ , / //;C �UK K Q� IY J/L r J lC CRY �++ LOT BQE= l—G <br /> OWNER'S NAME <br /> - TADIJIEBS // L Y <br /> CONTRACTOR PNOInE_ SJ Wf✓ <br /> /-' A£IDREBS <br /> BUB CONTRACTOR �G, /!/�GC� / �j /� txf PHONE ,t <br /> TYPE OF fDT11C M/ORK: NEW iNf71L1AT1oN REAPADdON <br /> bifiTxICTON❑ <br /> IND SEPTIC SYSIFM PEW`TTEO F PUBUC SEWER IB AVAILABLE WITHIN 200 FEET OF OWIDINO.) <br /> F41C TENTIFI L 1.HOW MANY <br /> 74NfTALLtTIONNWILL i�VE: RESIDENCE OT f <br /> COMMERCIAL❑ OTHER C� <br /> IR/AfL3L K ULLIRO LINNTf: f IA1JEgl OF EEOROOW'_ <br /> T�— c MSI OF BMPLOYg/I; <br /> CHARACTER OF Bot TO A DEPrN OF 3 FEET,� <br /> %TfSUMP SOit CHARACTER: WATER TABLE pEp{N <br /> fEPT1C TANIVQREABE TRAP ❑TYPE/NTFO <br /> CAPACITY NO.COMPAHI'MENTS <br /> NLD TAFATMIXf PU{P/T❑ IxfTANCE TO NFAl1EfT: WELL +. <br /> NO. <br /> PROFIRTY LIM J <br /> LFT STATION❑ ,L 7V'PE OF IW/MI / SAND OIL SEPARATOR 4ENCLOSEO SYSTEMI " <br /> LIACHI"LNlf �, NO.A LEACTH Of LINES 'T- Wit l <br /> DISTANCE TD NEAREST;WELL �PROPETTTY UN! -!e> -7 <br /> FILTHT IE, ❑WIDTH LENGTH DEPTH OISTANCF TO NEARELTT:Wnl- ---GGG��•�• '��� <br /> MOUIID® �y,�H fOVF40ATION PROPERTY Ltlf <br /> SMAOE PFTs LFNOTH DErr" DISTANCE TO NEAREST:WFU —FOUNDATION PROPERTY tMIE n <br /> ©� G <br /> �F-y�I SI`ze HUMSEA DISTANCE TD NEAREST:WELL FOUNDATION <br /> LLIIRNf U LM7TH --_ PROPERTY 11H! <br /> iDlG71V DEPTH DISTANCE TO NEAREST;WELL FOLAIDATION <br /> DISPOSAL PONDS ❑MOTH PROPERTY LN1[ <br /> STH CEPTH DISTANCE TO NEAREST!WELL FOUNDATION PROPERTY UNE ~ <br /> 1 HERESY CERTIFY THAT i HAVE►PEPAPfp THLS APPIICATIOH ANO 7HAT THE WOW .�. <br /> AND RMULATpNB OF THE'QAN JOAQUIH COUNTY.HOMEONREpaR Writ BE DONE IN ACCORDANCE IATFN BAN JOAOVHI COUNTY OPOM;ANCEB AND STATE LLWS,AND Rl1LEB O <br /> T108 p6Rl.RT IS WGUFD,I SHAD.NOT EMPLOY ANY UCENSEO AQFHT'B BIONATILRF CEFITIHESTHEMLLOWNQ:'1 CERTIFY THAT IN THE POOFORMANCE OF THfWORK FOR WHICHSUB-CONTMA _ <br /> WOMMAN'DC OM NSATI URE CERTWEQ THE FOUyOWMO:�-1 CERTIFY THAT IN THE PERFORMANCE OSUBJECT <br /> THE WOWA#OR W Wm TMW ppUHT HT E LSSULO,I SHALL EMPLOY PERSONS fMJCICT TO {C{^^ <br /> WDAILLAN'e COMPENSATION LAWS OF CAUFOIWA.•THE APMICANT MUST Cw-L 24 HOURS IN ADVANCE FIX4 ALL Allaur D INfI'6TIONf. COMPLETE DRAW WQ BELOW. L_ <br /> _.TmE: DATE__s :✓l��G'a <br /> ROT PLAN DRAW To SCALEI BCAK -le <br /> i.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br /> 3.OUT11"LE OF TIE PROPERTY.WITH DIMENSIONS AND 4.LOCATION OF HOVSE SEWAGE DISPOSAL fWEM OR PROPOSED <br /> f•dMQNiNONFtI Olfi NORTH LNRECTbN. EXPANSION OF SEWAGE DISPOSAL.BYSTe s. <br /> LINES AND LOCATION OF ALL EXISTINGWAY AND IHIOpB[D BIRLICTUREB, 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOREO FIFTY FT.ON <br /> DICLUDHLQ COVERED AREAS 0.CH AS RATIOS,DRIVEWAYS.AND WALILB. <br /> ........... -_ TH!PPOPERrY OR ACUOININO PROPERPf, <br /> TA <br /> Q o <br /> �.u. U 4 ............ <br /> v/. <br /> b <br /> J <br /> �`JC _1�A1ls <br /> 161, <br /> •.._..._ <br /> 1JMAR 19 <br /> .:.. <br /> �..-^ POrR OwARTTAp v uSI[ONLY <br /> APKWATIONAOCEPTEO BY T <br /> DATE: 1A• T <br /> tApfC RT OR PAW 1NB►ECFgNi'1LY <br /> (�L� ATE <br /> FINAL INSPECTION BY CATIE <br /> AOOTTgIIAi.CON,NETTTf- `�"' <br /> I j <br /> ACCOLIXT&O ONLY. AIDS <br /> FAC* <br /> pY COD! FEE IMO AMOl/1TT R9AITTID L11CMN .. <br /> a''ro fY PATE M I PINT RuMilm UA'O4CE f <br /> t <br /> yzto S b�c� �'t�3 a 9 <br />