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APPLICATIMI FOR LIOUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> uo" 301 EAST WEBER AVENUE,STbCKTON,CA 95202 <br /> R h (209)458-3420 a{/ C)C I <br /> MON•REFUNUABLE PERMIT EXPIRES YEAR FROM DATE ISSUED ��� <br /> ICBIRyMtt M Tr4Rlrt41 �l <br /> ARKWATION IS SKINNY MADE TO TILE OM1 JOAOLNN COUNTY FOR A PERMIT TO CONSTRICT ANOMR INSTAL THE WORK DESCMSTO.THIS APPLICATION POMADE IN COMPLIANCE w,rH SAN <br /> JOAQUIN COUN[Y DLTIEL.OA1l TALL,C"AP IER WI i i0.9 AND THE�ST <br /> A <br /> N <br /> D <br /> A <br /> R <br /> D <br /> S <br /> OF GAN MACAW COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL <br /> HEALTH DIVIWON. <br /> JON ADDINBBIORMNNf� qn0 (M-(7 CRY �_^ .��.-�J�l LOT F.IZ[ <br /> OWHEWS NAME l) �� G L 1'(-Il C-a J1 Yom_P[+I c ADDRESS PNONE l7 <br /> cafTMcrDR��C-W T Y21LI. V U L L C h ADD/IE9e r 'e 1 n G _�a T }{ f`/•I _ Llcf 3rLj.Cl 1-4,13 <br /> SVB CONTRACTOR ADOREb6 LIC/ PHom <br /> TYPE OF SE►TIC WORN: NLIYINOTALLATION❑ REPAIWAD01110N ❑ DElTM/CTIO <br /> WO SEPTIC SYSTEM PEM rMED IF PUBLIC.SEWER IS AVAILABLE WITHIN 200 FEET OF BULLDND.I PEI.T.l l 1 SOW MANY <br /> ADI Pllrbn♦_ <br /> INSTALLATION WILL SERVE: RESMENCE❑ COMMERCIAL❑ OTHER❑ <br /> NUM1101 OF LIVINO UNITS: NVABEI OF BFDROOMO: NI Ett OF IMPIDYLEt: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ PrT@1JS.4r SOIL CHARACTER: WATER TABLE DEPTS <br /> SEPTIC TANR/ORFASf TR�APT [ITYmwo CAPACITY NO.COMPARTMENT'S <br /> PRO TREATMENT PLANT U OtSTANCK TO NEAREST: WELL FOUNDATION PIOFFRrY Il <br /> LFT STATION❑ GRE TYPE OF PUMP SAND OIL BEPAIATOR(ENCLOSED SYSTEMI <br /> LFAC/BNO UNC ❑ NO.S LENGTH OF UNEB DISTANCE TO NEAAEBTI WELLFOUNDATKN PROPERTY UNE <br /> FILTER SED ❑WIDTH LENl­DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDrD ❑WIDTH LENGTH__DIEFTH DISTANCE TO Nall WELL FOUNDATION PROPERTY LINE <br /> Bill FTS ❑DEPT(/ NZf NUMBER DISTANCE TO NEALEOT:WELL FOLPIDATION PYIPE TY UNE <br /> GLWA ❑WIOTH LENGTH IVT" -- <br /> DISTANCE TO NEAREST:WELLFT.UNOATIOH PROPERTY LINE <br /> DRPOBµPONDS ❑WIDTH LENGTH DGIITH DISTANCE TD NEAREST:WELL fOUNDATIOH PROPERTY LINE <br /> 1 HERESY CERTIFY THAT I NAV[PREPARED THIS APPLICATION AND THAT THF WORK WILL BE DONE IN ACCORDANCE WITH GAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> AND RGULATIONB OF THE SAN JOAOLRN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWW('!'I CERTIFY THAT IN THE PEIIFOIIAAAJCE OF THE WORK FOR WHICH <br /> THIS PERMIT TO tOOPUED,1 SMALL NOT EMPLOY ANY PERSON M OUCH A MANNER AS TO INCOME SUBJECT TO WOIKMAN'B COMPENSATION LAWS OF CKIFORNA.• COHTMCTOWS HNYFIO OR <br /> SUBCONTMCTIW BgNATURE CEIITRRB THE FOLLOVANO:'I URTIfY THAT IN RISE FEISO RMANG[OF TH[WORK FOR W/i1CN THIS PERAM IG IBBVED,L SHALL EIIROY PEMONd dIIBJE[T TO <br /> WORKMAN'S COMFWGATION LAWG OF CALIFOMJIA.' THE APRICANT MUST CAL 24 HOW IN ADVANCE FOR ALLRSOUNUO INSPECTIONS. COMPLETE DRAVRNO SELOV. <br /> SIGNED /I �j <br /> OHIO X �"'"1^ �v}//0111 SIF,/1 LEC `'1L TR :__ DATE: <br /> \ <br /> ROT PLAN(DRAW TO SCAUI SCME <br /> I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TH£PMPFRTY. I. <br /> LOCATION OF HOUSE OEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AILD NORTH LXRECTP0N. EAPANBION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DAIENSIONED OUTTINES AND LOCATION OF ALL EXISTING AND PROPOGED STRUCTURES, S.LOCATION OF WELLS YNTHIN RADIUS Of ONE HUNDRED FIFrY f7.ON <br /> IMLU04HO COVERED AREAS SUCH AS PATNIO.ORIVEWAYO.AND WALKC THE PROPERTY OR ADUDNNG PMPERrY. <br /> P ..... <br /> ...,. . <br /> e c. <br /> t <br /> d <br /> AA SSSS ' <br /> (T-r <br /> gg S <br /> _ 1 <br /> PAY mtw I <br /> qECEiVED _... <br /> fi <br /> FEB 92004 <br /> mja+cwlN oalnTv <br /> � <br /> SE <br /> NyIM } <br /> Aw s ; <br /> ENVIROIc V-(-(P; <br /> (, R OEPAPrMFNY USB ONLY <br /> DATE: l <br /> AREA <br /> lJ <br /> APPLICATION ACCEPTED BY ' Ir�- ( � i oV <br /> GATE / MALNSHCTION DY DATE <br /> RANI(.lOR BUMP INOPECTlOH BY —� <br /> AL COMMENT <br /> ADOTTIONS�J�—�5 <br /> ACCOUNTNO ONLY: JUDI, FACE <br /> I PIRMIT NUMOL INVOICE <br /> PF COSI tat AMOUNT RUHIITED CIO_'C KASN ITEC BY PATE SR f <br /> A '6 -.r . -/_3 q <br /> P,Ib.Health Sere.-EmlrD 174(3P96) '�, / !- ,f.,n -� t•'�- -�' "_�"'�� <br />