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' APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ryn <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NQ(}_REFUNDABLE P"WT EXPIRES I YEAR FROM DATE ISSUED <br /> KAmpIS1S IS Tripluls) <br /> APPUICATION W HEREBY MADE TO THE SAN JOAOUN COUNTY FOR A RER.ST TD CoNBTPMT ANDJOR NSTALL THE WORK DESCRIBED, THIN APPLICATION IN MADE IN COMPLIANCL WITH BAN <br /> JOAOVN COUNTY DEV"PMENt TITLE,CHAPTER 0-111 0.3 AND THE BTANOAMD OF SAN JOAOUN COUNTY PUBLIC HEALTH SEIIVTCES.OFVSIOAMSITAL HEALTH OMMON, <br /> JOS ADORES"AN'WP 7 od?4— f�,[,L !i/L _cm !yG- Lur <br /> OWNER'S NAME�j A-1t i� ��, .S ApNE <br /> CONE/IACTOR_T2. XADOREee "2, G LR:I /.SSS IJ/ PHONE .4 ,x^11'/ <br /> BUB CONTRACTOR ADORESS IJCF AFORE <br /> TYPE OF SEPTIC WORK: NEW NATALLATION❑ ADANVADOITMIN DESrNICDON❑ <br /> NO BEPTTC SYSTEM PERMITTED if P:RBLIC BEW[A IS AVAKASLE WTTHIN 200 FEET Of BLALDIH(IJ PBC TDSTNI I I IK)w MANY <br /> INSTALLATION WILL GINWW RESIDENCE ,d COMMERCIAL❑ OTHER❑ <br /> NVMRET OF UVWO VISTS: NUSABER OF BEDROOMS: NUNIBM of EMPLOYE&: <br /> CHARACTER OF SDE,TO A DEPTH OF 2 FEET: PTfBUFAP 800.CHARACTER: -­" WATER TABLE DEPTH <br /> 6117111C rANKAPLA"TRwr-R 11 TYF{/AK A CAPACIFY NO-COMPIIAENTB <br /> PKO TREATMENT RAN-TT ED DISTANCE TO RIIARE�W WELL FOUNDATION PROPERTY UNE <br /> LFT STATION 0 TRE TYPE OF LUMP p SAND OIL StPARATOR IENCLOSED EYSTE W r 'T <br /> LNICRNG UNE 19 NO.S LENGTH OF UNEB­, •�O CJ y y DISTANCE TO NEAREST:WELL FOUNOATION�_PROPERTY LINE ?D <br /> FILTER BED ❑wuTH LENGTH— DEPTH DISTANCE TO NEAIMI T:WELL FOUNDATION RIOFfRTY UNE <br /> MOUNDED ❑WIDTH LENOTH__DEPTH DISTANCE TO NEAREST:VYELL PCUNOATION PROPERTY LINE <br /> SBVAAE M■ ❑DEPTH BRE NUMBER DISTANCE TO NEAFEBT:WALL FOUNDATION PROPERTY LINE <br /> NSAPS aN7D7N LEfgTH D"P.-Za OISTANCETONEAFEBT:VMELL�P FOUNDATION�FrFROPFRTYUNE •f�N'�r� <br /> DISPOSAL FORM ❑VAOTN LENOTH DEPIH DISTANCE TO NEAREST:WELL_FlOUNOATION PROFARfY UNE <br /> 1 HERESY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE N ACCORDANCE WITN'SAN JOAOUN COUNTY OIIONANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERrWWB THE FOU-&AVM:'ICERTIFY THAT N THE PERFORMANCE Of THE WOPK FORVAMCH <br /> TMS PERMIT IS ISSUED,I AUUL NOT EMPLOY ANY PERSON N SUCH A MAtNIN M TO BECOME SUBJECT TO WORKMAN"COLPENSATION LAWS OF CA.IFO1MA.- CONTRACTOR'S HIINq OR <br /> NB-CONPUCTTNO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAIN THE PERFORMANCE OF THE WORK FO'A WHICH THIS PIRIMIT IB IBSUM.1 SHALL EMPLOY PERSOM BUB.IMT TO <br /> WORKMAN"COMPORATION LAWS Of CALIFORAA.- THE APRT/CANT MUST LALL N HOURS N ADVANCt FOR ALL RRi01ARED INSPBTIONS.COMPLETE DRAVMNO BELOW. <br /> BFONED R ��s�i" Trru:_ DATE: r <br /> ROT RAJ MRAW TO SCALE)ACALE_ W <br /> 1.NAMES OF 81"1EET8 OR ROADS MEANEST TO OR SOUNDING THE PROPERTY- 1•LOCATION OF NOOSE SEWAGE DIplom SYSTEM OR PROrgem <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NO""ONECTION, EAPARJNON OF ll""E DISPOSAL SYSTEMS, <br /> J. DIMENRONEO OUTLIES AND LOCATION OF ALL EXIBTNO AND PIROPOGED RRUCTUIEB• S. <br /> LOCATION OF MILLS WFTFPI RADSN Of ONE WNDRED PIETY FT.ON <br /> INCURONO COVHEO AIlAB BUCH AS PATIOS,OPVEWAYS,AND WALKII. THE PROPERTY OR ADJOINING <br /> JL= <br /> C�EI E,;3 <br /> OAOUI �ljt'%, <br /> y..p•Ru Pvs D' F1�AL. n...ESMPi AL'M <br /> LA <br /> r� .....w I . <br /> . . _ <br /> .. m <br /> Y . <br /> ... <br /> • I � <br /> __.. nn-1 <br /> FOR OPARTMESI W111 ONLY ! L <br /> APPUOATION ACCEPTED BY 3_g' AREA; ff.. <br /> TANK,PR OR BUMP NBFE BYit _DATF_ / ! FINAL NSFECTION BY <br /> ADDITIONAL COMMENT •� V C w FV T� 0 <br /> ACCOUNTNO ONLY: NDP fAt! �-II� <br /> PF CODE FIN NFO AMOUNT REMITTED cIBK/ ABH R mrB SV DATE M!PERMIT NU/MBE. INVOICE F I <br /> 115 L SDq7u ITT- <br /> PUb.HSINth Sel •ETMrO.174 Pial) <br />