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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.Q.BOX 309,445 N.SAN JOAQUIN ST.,STOCKTON,CA 952014)3BB <br /> (209)488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRE$1 YEAR FROM DATE ISSUED <br /> Mompl/u h Tfiplim* <br /> --N IS HERFJSY MADE TO THE SAN JOAOU,N CWNTY FOR A PETBAIT TO CONSTRUCT ANDMA INSTALL THE WOW.DESCRIBED. THIS APPLICATION IS MADE N COMPLIANCE WFM SAN <br /> JOAOUM CDI.WtY DIFWLOPMO'EH'/TTTLJ;CHAPTEER7&'1110.3 AND THE STANDARDSS OF SA MAOUIN COUNTY PUBUC HEALTH SERNCES, ONM ILL HEALTH DINBIDN. <br /> JOB ADD RESSAI!APNIJ�t_�.fQ `==�. lP'T SIZE <br /> OWNER'S NAME IQ.,i]/�',r��ry," �r.�l�iC ^`ADDRESSf�cTTT —HE <br /> V�7._- y` I fsa JaS�•' 1 ••�I//r+++ytSE/rr�•iiiJ �/y <br /> CONTRACTOR (3 fyR C) ADORE LJCI/_� E('/y R1ON{�/ <br /> BUS CONTRACTOR ADDRI10 LJCI PHONE <br /> TYPE OF 65MC WORK: MEW INSTALLATION❑ WANVADDITION DESTRUCTION❑ <br /> IND SEPTIC SYSTEM PENIMITTED V PL X SEWER IB AVARJIBI_E WRWN ZDO FEET OF BUKJXNG,I R91C TS/TIRI 1 11K;W MANY <br /> APpcAIINn <br /> INSTALLATION WILL BINE REBIDEA'CE COMMERCIAL 13OTHER❑ ^1 <br /> NM61 INOF WINO UNR/: 1 B1 OF BEDROM <br /> O /: WRAEB ►Ig <br /> t OF RALYd'. <br /> CHARACTER of SOIL TO A—(DEPTH O'NlAr <br /> F 3 FEE,-; PITKUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKIaQASE TMP ❑TVPEWIM CAPACIrY NO.COMPAPITWNTS <br /> PKO TREATMENT PLANT <br /> �❑f DI/TAMC[TO NEAREST: WELLFOUNDATION rROPERTY LINE <br /> UFT <br /> WN <br /> LEA—ma UNE ❑Lq NO.4 LENGTH OF�OF AU AND OIL 5 DIGT ANLL TO NEAREST:WELL N o_PROPERTY LINE ^, <br /> FIETW BED '01WIDTH LENGTH DEPrH DISTANCE TO NEMEBT:WELL FOUNDATION PROPERTY UNE I}' <br /> MOUNDED ❑warn LENGTHTr DEPTH DISTANCE TO NEAREST:%NELL FOUNDATION -7 <br /> P'ROPER'TY LME_, <br /> S®ROE NTA XDEPTH ,ME_3 6" NUMSEA=DISTANCE TO NEMIEST:WELL]? TO Z DATION,PROPERTY UNE _ <br /> SUMPS ❑NROFH LENGTH—DEPTH DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY UNE <br /> MSMBAL MKOS ❑WIDTH LENGTH DEPTH DMANCE TO NEATEST:WELLFOUNDATION PRDPERTY UNE <br /> I HDESY CERTIFY THAT I HAVE PRET•ANED TTN9 APPUCATKON ANO THATTHE WDIK WSL BE GONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ONDINANCES Ira STATE LAW8,AND RULES <br /> AW REGUTATIONB OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UC EMBED AGENT'S SIGNATURE CERTIFWB THE FOLIOVANG:•I CERTIFY THAT IN THE PEAMFIMANCE OF THE WOW,FOR WHICH <br /> TNI.PERMTT IB ISSUED.I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUSACT TO WORKMAN S COMPENSATION LAWS Of cAJFO118A"CONTRACTOR' <br /> SW HNPBNL OR <br /> SUBCONTRACTING SIGNATURE CEPTIFES THE FOLLOWNO:'I CEKTTFY THAT IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PETKBT LB I$aUEO,1 SHALL EMPLOY PERSON.SUBJECT To <br /> WORKMAN'S COMPENSATION LAWS OF CAUFORNI E APPL,CANT MUST CALL 74 HOURA IN AOVMCE FOR ALL.RAGUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> ✓ /���/1 lJ <br /> ! J P �Ln/I L}�,Q/f <br /> TITLE: <br /> SIGNED X [ ./.��YJ _GATE: <br /> ROT PLAN[DRAW TO SCALL SCALE-- <br /> NAMES <br /> CALE __NAMES OF STREETS TY <br /> OR ROADS NEAREST TO DR BOUNDING THE PROPER . A.LOCATION Of HOUSE SEWAGE DISMS-SYSTEM ON PROMISED <br /> E.OUTLME OF THE OROFFRTY,WITH DIMENSIONS AID NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED 0UTUNEB AND LOCATION OF ALL EXISTING AND PROPOSERI <br /> D STCTURES, E.LOCATION OF WELLS VRRIIN RADIUS OF ONE HUNDRED PIETY FT.ON <br /> INCLIIOING COVERED REAS SUCH AB PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> :....i ...... r ... ... <br /> ..i <br /> ............. .....e... '...!...... .. ..... N ... <br /> r ..-.. <br /> ,/ _....: <br /> - <br /> of <br /> :........... <br /> RA e ' ..... .. ..... <br /> NOV-: 8199 <br /> JAli1 Jt .. SiI'>r tAl:Iv ry .... ...... <br /> l U9L(rH�ALT.rNSeh'v.1 :E` <br /> )rlJsiaCSNFd2 fA.HdAI ' r ba . ....... <br /> FOR DEPARTMENT USE ONKY [c <br /> APPLICATION ACCEPLEO 6'Y C DATE: '�A._.—i.�—'� <br /> TANK.PT OR BIRAP INlPECTIDN 6Y GATE / f FINAL INSPECTION 6Y DATE1/l�- <br /> --------------------- <br /> .R <br /> ADOMONAL COMWNTS: <br /> ACCOUNT'AO ONLY AIDE FACE <br /> A CUpEIR NFO AMOVNT REMITTED cHlx ASH BELOVED BY DATE SN I FR3SAIY NUMBER WYOICE E <br /> 6}2 D a3 c <br /> S boo? 4 3 <br />