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G <br />APPLICATION FOR LIQUID WASTE PERMIT <br />SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 586, 504 EAST WEBER AVENUE, STOCKT(M, CA 95201,988 <br />(209) 4BS-3420 <br />MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IIJUED �ai � <br />ICBIRFIBIa In Trplleete) ��•3d3S"o% <br />APPLICATION 18 HEREBY MADE TO THE SAN JOAOLAN COUNTY FOR A PERIArr To CONSTFUCT ANDIOR INSTALL THE WORK DESCMEO. THIN APPLICATION IS MADE IN COMPJANCE VATN DAN <br />JOAOUMI COUNTY CEVELOPMENT TrnE, CH <br />APTER 9-1110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH INEENKWES, ENVIRONMENTAL HEALTH DIV13!ON. <br />JOB ADDRESBpR APNi,JSJ 7� ���./ Oi% a CTry �J (�hGIS ILS/f/ LOT SIZE.:--' G"/C/ <br />OWNER'S MAME <br />V <br />cGNrRACTOR_P✓�i ddaesfPHONE <br />__ <br />BUS CONTRACTOR ADDRESS UCI PHONE <br />TYPE OF A&-= WORK- A'EW N/aTALIATION� PWAMADDITMAI ❑ DEarRmm-i ❑ <br />IND SEPTIC SYSTEM P ""TIED IF P1SUC SEWER IS AVAILABLE WITHIN 200 FEET OF SIItLDRRI.I POW TESTW I 1 NOW N.AJtY <br />APStoatm E <br />INSTALLATION WILL S@UVE: RESDEF/CF,k, COMMSACIAL CI OTHER ❑ <br />MUMMER OF Lr4M UNITI! 1� NUMBER IIF IISDROOMS:NUMBER OF BNrLayna: <br />CHARACTER OF SON. TO A DEPTH OF 3 FEET: r <br />.-YRTI/SEN�AP SJOS. CHAIIACTEq:�{ . WATER TAS(E DEPTH /_-k-;)SEPTIC TARRADRFANE TTAP ❑TYM(IMPO_ / Z)CJ / e CAPACITY N0. COMPA/rtMENTB <br />MO TREATMENT PLANT ❑ C-%TANCE TO NEMNAY: VVELL FOUNDATION CROt4RrY LINE <br />UFT STATION ❑ SIZE TYPE OF PUMP SAND OR SEPARATOR (ENCLOSED SYSTEM? <br />LEACNNO LINE M HO. N LIENOTH OF IJNE9 .4 J/ <br />[� DrSTANCE TO NEAIIEDT: WELL FOUNdATpN :2-4" PROPE1rTY LM/D <br />FALTER SEO Cl WIDTH LENQTH__DETTH DISTANCE TO NEAREST: WELL _FOUNDATION PIaiP'ERiI'UNE <br />MOUNDED ❑ mOTN IENQTl1 1_ MPrH DISTANCE TO WARIEST: WELL FOUNDATION PROPERTY UNE <br />SEITAOE nTa .®.DEPr,{ �,f ! 312E NUMBER_ dBTANCE TO NEM%M; VVBL�JI FOVNUATpM POpERTY 1111E /(7 - <br />SIANri ❑ mum LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />OIaPOSAL MNDI 13 WIDTH LEST <br />NGTH DEPTH DISTANCE TO NEAREST; WELL _—FOUNDATION_ PROPERTY LME <br />1 HERESY CERTIFY THAT 1 HAVE I MPMED THIS APPLICATION AND THAT TM`. WORK WILL Be DONE IN ACCORDANCE WfTM SAN JOAOURN COUNTY ORdNAHCE3 AND STATE LAWS, AND RUIlE3 <br />AM PEOURATIONS OF THE SAN JOA WIN COUNTY. ROME OMRIER OR LICENDEU AGENT'S SRONATUM CERTRFKS THE rfl110WIH0: '1 CERTIF7' THAT IN THE PERFORMANCE OF THE NOISC FOgm#CH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME DUBJECT TO VOMMM'S COL4po"ATION LANES OF CALWO"NtA,' COMp%ACT0IYS,,FOR <br />STRTLOMRACTING 61GNATURE CERTIRE3 THE FOLLOWING: '1 CERTKY THAT M THE PERFORMANCE OF THE WOtK PORVVHICH TMS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WOWMAN'S COM SATIOH LAWS OF CALIFORH(A.• THE APMIOANT MUST CAL(. 24 HOUR, IN ADVANCE FOR ALL rrEaPRRIy <br />m aPECTIONt. COMPIJ:'TE DRAWING BELOW. <br />SIGHED / <br />TP'lF: �iG /%' DAT[: � 2$` <br />PLOT PLAN (DRAW TO SCALE( SCALE • to <br />1- NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINQ TES: PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEEI OR PROt'OBEO <br />2. OUTLINE OF THE PROPERTY, WITH DIMENSIONS MENONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMe. <br />LL <br />2. DIMENSIONED OUTUNES AND LOCATION OF AEIIIMNO AND PROPOSED STRUCTURES. 6. — <br />J) FOR DEPA ENT NaE ONLY <br />APPLICATION ACCET^ED BY \42 I DATE: aREA.v�-^ <br />'5F9. <br />j f�' <br />N ,////�R ""'P "MICTION BY DATE ( /FIN.11 NIB PECTION BY aA4 Lj <br />ADDITIONAL COMMENTS: T' <br />ACC11UHTIN6 ONLY: -ID/ PACT i <br />IE CODE FEE INFO AMO T REMITTED EC!V NH RECBYFD ST DATE fR ! rTPStaT ft"ER. <br />iNVIXCE I ! � <br />77 1 j �C ITM31oa L +3 alas Q <br />