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APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 466.3420 1/ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o <br />(c" IEq Is Tripieat►1 <br />APFUGATOON IB HEREBY MADE TO THE SAM JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT A DKIR INSTALL THE WOR( DESCRNED. THIS APPLICATION IB MADE IN COMPLIANCE HATH BAN <br />JOAOUN COUNTY L%VEOPMENT,TTTLL CHAPTER 9-11 -1 0.3 AND THI STAHOAFM'OfJ, EI ?OAQUIN COUNTY PUBLIC HEALTH BETIVICE�'ENVEIOMAFMM HEALTH OMSgN. <br />JOB AOORESSADR AAn7WtJ)I, <br />OWNER'S NAM§IT./� <br />LOT SQ�`� ✓ - r - <br />CONTRACTOR/ " 'O_`>1d' r -4-` , ADDR 614-- n• "ff -'t • 5,rLN:► C C S _ PHDN&W7 3 -') T_3 <br />BUB CONTMCTO0. ADOMSS LIC► RNONT <br />TYPE OF SWORK: NEW INSTALLATION ❑ Rg <br />EPAIMADOITN OFJTRUC710N <br />EPTIC ❑ <br />ONO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WIT IN 200 FEET OF RKLINNO.I WIC TFSTpI f I HOW MANY <br />APPEoAto� I <br />INSTALLATION WILL SERVE: RESKOENCE 0 COMMERCIAL ❑ OTHER ❑ <br />MUMMA OF LMMG UMTS: NUMBER OF NWROOMS: NUMBER OF EMPLOYEES: <br />CHARACTER OF SM TO A DEPTH OF J FEET: PR/SUMP SOI CHARACTER: WATER TABLE DEPTM <br />SEPT TAMUNIEASE TRAP ❑TYPEWO CAPACrTY NO. COMPARTMENTS <br />PKO TREATMENT PUNT ❑ DISTANCE TO MEARIEST: WELLFOUNDATION PROPERTY UNE <br />UFT STATION ❑ BRE TYPE OF PUMP / SAID OR SEPARATOR (ENCLOSED SYSTEM) <br />LEACHING UME W. B LENOTH OF LINES �7 -7 O / DISTANCE TO NEAREST, WELLFOWOATION PROPERTY UW <br />FILTER SW ❑ WIDTHLENGTH DEPTH DISTANCE TO NEAREST: WELT FOUNDATION PROPERTY LWE <br />MOUNDED <br />WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE O <br />SMAGS PITS 1J DEFTH­�-_-'V SIZE ri NUMBER r DMTA14CE TO NEAREST: WELL FOUNDATION PROPERTY LANE 1 �j <br />SUMPS ❑ WIDTH LENOTH DEPTH INSTANCE TO MEANEST: WELL FOUNDATION PROPERTY UNE <br />DISPOSAL PONDS ❑ W DTH LENOTH DEPTH DISTANCE TO MEUESTI WELL FOUNDATION PROPERTY LINE <br />R HERESY CERTIFY THAT' <br />NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS, AND RILES <br />ANOROU(ATIDNBOf THE8ANJOAGUNCOVNTY. NO ORIJCENSEDAGEMT'SSIPNATURECEFMRESTNEFOLLO%VWG:9CERTIFY THATNTHEPfNCEOFTNEWVOWSHAWHICH <br />NGO <br />TMS PEISAR q D. SHALL MOT EMROY ANY N A MAIRER AS TO BECOME SUBJECT TO WORKMAFTB COMPENSATION. OF CALIFORNIA.-LD:fIMCONTRACTOR'S IIPoNO OR <br />SIISCOM1iACT1 TURF CERT ARES THE FOLLO : 'I CERT( THAT N THE pIERPONIrAHCE OF THE MONK FOR WHICH TM 111 IS ISSUED, I SINAL EMPLOY PERSONS SUBJECT TO <br />WORSCMA IT MPEN INN LAWS OF CAUFORNIA.' APPLICANT T CALL 24 HOURS IN ADVANCE FOR ALL PWTIONS. COMPLETE ORAWNGsnow. <br />i <br />TITLE! DATE: ' l <br />STONED X <br />PLAT T SCALE) SC ' H, <br />1. NAME OF O ADB NEAREST TO THE - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRIOPOSED <br />2, PROPERTY, WITH DIME SIO 8 ATO NORTH pWE"ON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />J. DIMENSIONED OUTUMES AND LOCATION OF ALL EKNITINO AND PROPOSED STRUCTURES. i. LOCATION OF WELLS A J WITHIN RADIUS OF ONE HUNDRED FIFTY Ff. ON <br />M(CLIAINO COVERED AREAS SUCH A8 PATIOS, DRIVEWAYS, ANO WALKS. THE PROPERTY OR AQ10MN0 PROPERTY. <br />....... <br />v _ <br />... <br />........._.. <br />,q <br />L <br />_ r <br />Ay; . <br />L CIN S. <br />REC:JUL <br />�i�1�lC <br />Q <br />.OUi(R,1.A+i:IU,lSC1LNLIi!15Y <br />�tlBtJC HEAIlH BERVICE�! � . <br />k?MNOMAIEP�1IAL EALTk 0I1Q51UM: �v <br />FOR DEPARTMENT USS ONLY <br />APPLICATION ACCEPTED BY DATE: - <br />TAMC. PIT OR BUMP NBPECTOH BY DATE / / FINAL MBPECTION <br />ADDITIONAL COLIAENTS. <br />ACCOUNTING ONLY: I AIDS <br />FACS <br />{I R CODE _ 1 FEE WFO ` AMOUMT REARTEV I HFC( KASH I RECEVm BY I DATE. SR 0 PSR.BT NUSB6L I NVOICS S II <br />Pub. H&I Sem. • EnAra. 174 ("6) <br />