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f APPLICATION FOR LIQUID WASTE PERMIT <br />�- SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 60741-1, <br />(209) 468-420 !!SS <br />PON-REFUNDARtt FtNMIUXpMS I ye4g F,OMD 6U <br />(GtSTgMtt M EF1j8atEl <br />APRKATKIN Al /ERFBY MADE TO TIE BAN JOAO111N COUNTY FOR A RFCJFF TO CONIDICT ANDpR NFTALL THE W _ DECCPLSED. TMC APPUCATPON4 I N �COMPLIANCE VMHH SAN <br />JOAOUN COUNTY DEVELOPMENT TIRE. CHAPTER 9- t I 10.3 AND TETE STANDAPbe OF CAN JOAOUN COUNTY MULIC HEALTH SERVICES. CWJMNMENTAL MALT" ..ARRAN. <br />JOB ADORESBIDR APHI • ,R 11-kel I/ <br />J f tOi H2E <br />OWNER.* NARK �. /r�Fi." / �. ! / /l I C �_.. ADOMEAR Sl,( Li(/ {) .e /_:• .. •? A . . <br />y <br />co �/I f I N i r/J /! I O ADOIEBC J eA S 11- <br />PHONE <br />- <br />#U8 CONTRACTOR ADDRESS U•F MORE <br />TYR OF fEPTIC WOR[: NEW NSTALLATION ❑ RMANUADDITION OrATRMM" ❑ <br />NO tFPI Ic svtREM P,cRrwTTEo E P.INLIc SEWER IS AVANLASLE wrrMN <br />200fretor"Im NO.1 FEND 11STM 1 I "m MANY <br />AIMSSSMe I <br />INSTALLARON 11Y/li SlRIKI RSIUENGE � COMNAERCIµ ❑ GINNER <br />NUMCDI OF LMNo IMM: e1 OF BEDROOMS NIENSEI Of NMROYFEC: <br />f, CHARACTER OF SOK M A DEPIII OF 1 FEET; FTTISUMP FOR CHARACTEIC WATER TANU DEPTEI_ <br />SERC TARMIREAM TRAP ( >^i gt"0FAMFO CAPACm NO. COANARTMFNTS <br />RIO NIEATME7IT PUNT Q gATARCF TD RFARST: WELL_/,,- FOUNDATION PROPERTY LINE <br />tWT STATION ❑ SRE TYPE OF Pujmp SAND OK SEPARATOR ENCLOSED SYSTEMI <br />LEACHNO UNE 0 -'NO. A LENGTH OF LNES�I + : / /f DSTANCE TO NEARE RTI WELL FROP[RlY RINE <br />RL7E1 SFD ❑ WETNI RENOIR DEPTH DISTANCE TO NEAREST! VAU FOUNDATION FTgRRry INF, <br />MOVIIOft [} WROTH LENGTH DEPTH OMTANCE TO WAFM WELL TOIINOAITOM PROPERTY UNE <br />EEPAOE NTS ❑ DEPTH *DE NUMBER DNANICE TO NEAREST; VffU MURDATION FROM" UNE <br />BUMM P WIDTN_�. {HgiN f �.. DEPTH / (% LNSEAICE TO HEAIEST: WEIR LA(2 FOt*MAMN PROPERTY UNE <br />OMPMAI PONOS ❑ WDTN LENOTH DEPTH OISTANCE TO NEAAESTI HELL FOUNDATION PROPERTY LIVE <br />1 "EMERY CERTEY THAT 1 HAVE PREPARED TMS APFI&ATION AND THAT THE WONK WILL M DONE N ACCORDANCE NTTH SAN JOAOIIN COUNry ORdNAM" AND STATE LAWS. AND RULES <br />AND REGULATIONS OF THE SAN JOAUIIMN COUNTY. HOME oWNER LIILUCEHND AGENT'S EONATUR CEIITINEC THE MLLOWRIOI'ICERHFYTHAT LATHE Kl"MMANCE Of THE YORK FOR WHICYI <br />THS PERMIT IS R HIED, 1 SHALL HOT EMPLOY ANY PERSON N SUCH A MANNER At TO BECOME SUB.IECT TO WORKMAN'S COMPENSATION LAMS OF CAUPOPMA.• COMRACTOIFS NSSML OR <br />SLSCONTFNCTNO SMNATIRE CEDINES THE MLLOWDD: '1 CER7SY THAT IN TH <br />THE MFVmAMANCE Of E MIOM FOR WHICH TIRE PERDU IS ISSUED. 1 SHALL EMPLOY MASONS SUBJECT TO <br />WOKMAN'S COMPENSATION LAWS OF CALF/IIIA.' TILE APPLICANT MUST CALL U HOLM N ADVANCS FOR ALL IDNDIAR®gSC <br />S/FFNINS, COMPLETE DRAM BELOW. <br />BIOMED A •.-,�.> / t it1!%7t% — TME: �%7aZ'C oATE:_ ✓ _ / •- <br />// PLOT RAN RIIMW TO SCALD SCAN • N <br />1, �N-AMES 6i CTFEET11 OR ROA06 NEAREST TO OR ROUNDING TIE PROPER, V S. LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR RIDPOSED <br />2. OUTUNF OF TEE PROPERTY, MR OSAENSIOHa AND NORIA DIRECTION, "PANSIDN DF SEWAOE DISPOSAL SYSTEMS. <br />J. dMENSpNED OUTLIVES AND LOCATION OF ALL EX187M AND RIDPOSED STRUCTURES, S. LOCATION Of WELLS 1NRHN RADIUS OT ONE RNbAEO FIFTY R. ON <br />1 /L\ FOR DEPARTMENT USE ONLY I 1: I <br />ANVCATION ACCEPTED SY, r•.•\ `.%_Llal ♦',.(�F-"(� DATE: ARA: <br />TAM, fTF OR MFM►LNCI'ECT/ON SY <br />DATE <br />"NAL NSPECTI/I�N BY <br />DATE <br />IM <br />ADTIONAL COMMENTS: I�y�r b�L <br />�l.�lA <br />/ <br />%/J�j z 1'1�7 <br />GGA <br />ACCOUNTINO ONLY: ADI <br />FACT <br />M CODE FEE INTO AMOtNi REAITi® <br />(C71[CIVkASH <br />RREYEn SY <br />DATE tlllFeSIET MSIAEIL <br />INVDICES <br />. ; � � �, `7 " rl�j <br />��, o : �' <br />(.�.• <br />'�t Ni t, <- r''/ :.rte-L'� <br />... , �:, N;Ir'- lG . <br />Pub. He M ftm. • EmAm 174 <br />