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i <br /> APPLICATION FOR LICUID WASTE PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,446 N.SAN JOACUIN ST,STOCKTON,CA 96201.0388 <br /> (209)488.3420 <br /> NOR REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> (ComOMu in TRiplint►) ._ <br /> APPLICATION IB HEREBY UADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMRJAAICE BAN <br /> JOAQUIN COUNTY DEVELOPMENTTjTITLE,CHAPTER 81110.3 A/�N-L�(�TLE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SLER�VICER, NVIRONMENTAL HEALTH DMSION. J /� <br /> JOB ADORESSlOR ARiI / / 9 • •� �'+ /siLfll/' "J Q� LG pZF 3A,i^ <br /> OWNER'S NAME 1 (O ADD 33 �j q O x GP/�� !,)�� I PHONI� •�/��/ <br /> CONTRACTOR 0V f o X, (7 WAY S4, ADDIMEBS / / f �4T'G_ht 0a�r uc,T `� R­Ne-7-1/ <br /> SUB CONTRACTOR ADDRESS Uc- RIONE <br /> TYPEOF SISFM WORK: NEW INSTALIATIOM It REPANUADRXTON❑ DgTRMCTroN❑ <br /> IND SEPTIC SYSTEU PERMITTED IF PUBLIC SEWER IS AVAILABLE WMAN 200 FEET OF BUILDING.( —TES1H)I L NOW MARY <br /> Apda►oR P <br /> INSTALLATION VMI SERVE: RESIDENCE COMMERCIAL❑ ty`OTHER 13NUMSOI OF UI UNITS: 1 WL ISM OR BEDROOMS: T MUumm OF&APLOYRB: <br /> CHARACTER OF SOIL TO A DEPTH Of 3 FEET: PITISUMP BOX J� WATER TABLE DEPTH <br /> SEPTIC TANK"ALAK ITN ❑TVPEMFO 'C fI0 CAPACITY <br /> �'I'I D�V NO.COMPARTMENTS R <br /> PKO TREATMENT RANT❑ DISTANCE TD NEAREST: WELL / b FOUNDATION •'� ITIDPERTY UNE /p U <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND DR.SEPARATOR(ENCLOSED SYSTEMI n <br /> UNMTION <br /> LEACHING UNE 13 NO.A UENOTH OF LINES �O O DISTANCE TO NEAREST:WELL f J FOPROPERTY LINE /O <br /> FILTER BED ❑%mnTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTHY DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ <br /> !@ADE PIT{ ❑DFPTN ♦ SIZEiT;q_NUMBL/1 AN TO NEATEST:WELL,�0o FOUNDATION /4 PROPERTY UNE_ <br /> awn ❑W1OTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND RATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN!COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOWIA.'CONTRACTOR'S HIRING OR <br /> SUB_CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COOMMPENS�ATIIONN LLAAW.S Of CALFORNIA.' 7 ARWLIC 11 CALL 14 1 1 RN ADVANCE FOR ALL"IARED"INS, COMPLETE DRNW—BELOW. <br /> SIOf/ED X_=!� A"] ' � TRLf: CE O p DATC <br /> ROT RAN IOPAW TO SCALE)SCALE 'tO <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PMDPERTY. 4.LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DMAENSIONED OUTUNEB AND LOCATION OF ALL EXIBTINO AND R SED STRUCTURES, S.LOCATION OF WELLS—.1.RAONS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,MVEWAYB,AND WALKS. THE PROPERTY OA ADJOINING PROPERTY. <br /> �Z 6 <br /> We . <br /> .... <br /> 1: . <br /> X60 <br /> .............. 0:.. <br /> ......................... <br /> i....... ........ . <br /> : . <br /> f ... .. :. <br /> �D <br /> ......... ..... .. <br /> -.... .��... ...�E.. .. .... .......... ......_......_....... _... ... .. ..........._....._. <br /> . ... ... <br /> DEPMTMFNT IqE ONLY � J <br /> APPLICATIGN ACCEPTED BY / DATE: ,yJ AREA 0,3 <br /> / <br /> Ge <br /> /1"PN+�rPC OR BUMP INSPECTIO/JN BV c�/ (:z <br /> AT l I L <br /> Ut1NSRCTION BY <br /> LAD/DRIvON/1L COMMENTS: / `J/T O O z fy <br /> ACCOUNTING ONLY. AID- FACE <br /> PE CODE FEE INFO AMOUNT REAMTTFD CHEC (CASH RECEIVED BY DATE N/PERMIT NIMIB BR INVOICE P <br /> `lz <br /> DO d <br />