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r-"" APPUCATION FOR LIQUID WASTE PER t n <br />SAI. JOAQUIN COUNTY PUBLIC HEAL IN S—VICES V� <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEEDER AVENUE, STOCKTON, CA 952021 <br />(209) 46&3420 EX IY RE <br />PON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICaEPLEte in Trwww <br />APPLICATION IS HERESY JADE TO THE SAN JOAGUIN COUNry FOR A POWIT TO CONSTMJCT ANDMR INSTALL THE WORK DESCRIBED. TNS APPLICATION IS MAGE IN COMPUN E IRTH BAN <br />JOAOUSI COUNry DEVELOPMENT TITLE. CHAPTER B -T 110.7 AND THE STANDARDS OF SAN JOAOUIH COUNTY PUBLIC HEALTH SERVICE/. ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADONEBBNR AFNE <br />OWNER'S NAME ,MI. <br />SUS <br />TYPE OF SEPTIC WORN: NSW'INSTALLATION ❑ RFEAIRIADDITION ❑ <br />ONO SEPTIC SYSTEM PEP"TTEO IF PLIBIIC SEWER 18 AVAILABLE WITHIN 100 FEET OF BUEDINOI <br />PHONE <br />DESTRUCTION^ <br />POMC TESTNI I 1 HOW MANY <br />APMPSEa 0 <br />INSTALLATION WILL SEINE: RESIDENCE ❑ COMMERCIAL ❑ OTHER ❑ <br />MLINAM OF WINO two; NWSEU OF SCOROOMS: NWSOR OF SMPL.OYSES: <br />CHARACTER OF SOIL TO A DEPTH OF J FEET: PITABUMP BOIL CHARACTER. WATER TABLE DEPTH <br />SEPTIC TANKNREASE TRAP ❑TYF'FAIFO CAPACITY NO. COMPARTMENT <br />PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LTM <br />UFT STATIN ❑ AVE TYPE OF PUMP SAND OE SEPARATOR ENCLOSED SYSTEM) <br />LEACHING UNE ❑ NO. S LENGTH OF LINES 01ETANCE TO NEATEST: WELL FOUNDATION PFgfERTY UNE <br />FILTER SED ❑ WIDTH LENGTH DEPTH DISTANCE TO NEATEST: WELLFOUNDATION _ PROPERTY EINE <br />MOUNDED ❑ wtrrm LENGTH DEPTH DfUTANCE TO NEAREST: WELL POUNOATIDH PROPERTY LINE <br />NEPAOE RTS 17 DEPTH am NUMBER DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />SMARTIE ❑ MOTH LENGTH DEPTH DISTANCE 70 NEAREST: WELL FOUNDATION PHOPERTV UNE <br />DISPOSAL PONDS ❑ MOTH LEHOTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br />1 NOWSY CERTIFY 714AT 1 HAVE PREPARED THIS APPUCATION ATA THAT THE WOw WILL BE DONE N ACCORDANCE WITH SAN JDAOUIN COUNTY ORDINANCES AND STATE LAWS. AND RUES <br />AND REGULATIONS Of THE SAN JOAOUIN COUNTY. HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLC%%VM:'I CERfIFYTNAT INTHE PdiORMANCE OF THE WORK FORT NICH <br />THIS PERMIT W ISSUED, 1 MALL NOT EMPLOY ANY POISON IN NCH A MANNER AS TO BECOME SHI.IECT TO WORKMAN? COMPENSATION LAWS OF CALIFONMA' CONTRACTOR -8 WPM OR <br />SUS40ONTRACTIM6410NATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFOM/ANCE OF THE WORN FOR WHICH THIS PEr"T IS ISSUED, I MAIL EMPLOY PERSONS SUBJECT TO <br />VWTSLMAN' SATION OP TM ANT MUST CALL N HODU N ADVANCE FOR ALL RSSRSJI/nIm SYS►�TIONe, CONPLL7E DRAWING SElDW <br />sIGIED X TRlE:�Ny{�-�/I DATE <br />:i.�_ <br />RAT RAN DRAW TO SCJ1Lfl SCALE ' ro <br />1. NAMES OF STREETS ON ROADS NEAPEST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR PROPOSED <br />1. OUTLINE OF THE RLDPE TY, WITH <br />DIMENSIONS AND <br />NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. ONENBONED OUTLINES AND LOCATION OF ALL EXISTIND AND PFCOP08ED STRUCTURES, E. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. ON <br />BPCLUDING COVERED MEAS SUCH AS PATIOS, DRIVEWAYS. AND WALLS. THE FIROPERTY OR ADJOINING PIOP0ITY. <br />LOT WE . <br />-. <br />APPUCADON ACCEPTED By <br />TANK, FIT OR SUMP WSK(:TIOH <br />ADDITIONAL COMMENTS: <br />`A'4'a `.tet L/ \ U <br />DEPISTM USE ONLY <br />DATE: -7 AREA: <br />DATE I I FINK INSPECTION 8Y DATE I 1 <br />ACCOUNTING ONLY: <br />AID1 <br />FACS <br />PE CODE FLE INFO <br />AMOUNT RHAITm <br />C11ECR) SN RECEVm BY <br />DATE <br />U FSBAIT NLM6Hi INVOICE I <br />Pub. Health Saw. - EmUo. 174 (3W) <br />