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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES APN lL4 !;�7n1 y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PA 13OX 888, 904 EAST WE13ER AVENUE, STOCKTOR CA 9MI�388 <br /> 1209) 408.3420 <br /> NOK-REFUNPAIIIE PERMIT EXPIRES I YEAR FROM DATE I39U <br /> 0ampi16tM In TrIRR6BtM1 <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DEBCW6ED. THIS APPLICATION IS MADE RN CGLM jAIRCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 10.3 AND THESTANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,EMM ONMENTAL HEALTH DIAIWJN. f <br /> JOB ADDRESBKSR APNO L'./+D� 7 5 vq 112� f CrTY � C n �LOT W2E I•�J 4C. <br /> OWNER'S NAME IC �iS.�LLS1.th k �7 ZWSO M ADDRESS o 5 ?. 1'1 PHD!�E //p�f d 7�7/7� <br /> CONTRACTOR ERE[- i-&MaJ� ADDRESS r23Z Ellex+✓d0 _rJ �("�[jf 6 ��OZ �PHONE sO f yS7I <br /> SUB COWRACTOR AWRE66 LIC/ RPONE <br /> TYF1 OF SEPTIC WORK: NEW INSTALLATIO RWARVADOI DESTRUCTION ❑ <br /> INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILARE WITHIN 200 FEET OF SUI .I FDIC TEMThy[ T NOW MANY <br /> APFEom*n <br /> INSTALLATION WILL SERE: RESIDENCE rat COMMERCIAL ❑ OTHER El <br /> HUMOR OF LIVING UNITS: NLOBW k*BEDROOMS: -.-3 � NUN16@t OF EMFLOYITi6: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PfrmmP 6OIL CHARACTER: ��Wy}ATEER TALE DEPTFI_ 6- <br /> SEPTIC TANKMML"E TRAP &LTY"Am-� CAPACITY AWF' 779 NO.COMPARTMENTS <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL—/.Z D/ FOUNDATION Z S, Pmary Y LBO 50► <br /> LIFT STATION❑�61/ZE TYPE OF PiIMP SAND OR SEPARATOR{ENCLOSED SYS'TEM1 N <br /> UEACIMNO INNS lw NO.A LENGTH OF Uwe _, $70, �DISTANCE TO NEAREST:WELL I�r PJUMATION I� FROPENrY LINE�� <br /> FILTER B® ❑WIDTH LENGTH..DEPTH DISTANCE TO NEAREST:WELL ,FOUNDATION PROPERTY LINE <br /> MOUMOW ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL f FOUNDATION PROPERTY LIRE <br /> 68PAYE FIT! ❑DEPTH SIZE _NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONOM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIFE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOMANCE RTH MAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> AND REGULATION$OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEII OORMANCE Of TOE WORK FOR WHRCN <br /> TIAS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME BUBJECT 7O WOFAMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S MrSM OR <br /> SUB-CONTRACTIHO SIGNATURE CERTIFIES THE FOLLOVANO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEIIMIT I6 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WOI6(MAN'$COMPENSATION LA OF CALI IA.' THE APPLICANT MUST QALL 26 HOUFRS IN ADVANCE FOR ALL REQUIRED IRSPWTLONS. COMPLETE DPAWHO BELOW_ <br /> SIGNED X TPrLEr (fan!sac" r' DATE:_�Y-DZ <br /> PLOT PLAN(DRAW TO SCALEI SCALE M-T•S. 'to <br /> 1_ NAMES OF STREETS OR RDADS NEAREST TO OR BOUNOING THE PROPERTY. 6- LOCATION OF HOUSE SEWAGE ORBPOSAL SYSTEM OR PROPOSED <br /> 2. OUrLWE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 6YTF WMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 1. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDtRED FIFTYFT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PRDPERrY. <br /> :. <br /> r� <br /> vmm <br /> l <br /> r� .. . E . . <br /> p.: <br /> 300 . COU <br /> lu <br /> : <br /> OAN l <br /> :.. <br /> A <br /> If V <br /> r <br /> VOJ' j G O <br /> : <br /> Sa. . <br /> ...QCk <br /> CFO <br /> 2oo... <br /> ..,.., ...... ... .. et . ..... .. ............... . ...:................. . <br /> APPLICATION ACCEPTe'b BY DATE: <br /> TAM M€,PIT OR SUP INSPECTION BY bATEI6 J& /2FI14AL INSPECTgN B DAT O� yy 1 N J <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AOI FACR <br /> rE CODE FEE INFO AMOUNT REMITTED CHECKI A6H RECEIVED BY DATE SR I PEIMMT NU 1110% NIVOIGE R <br />