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4PPLICATION FOR LIQUID WASTE PERMIT <br /> .. SAA"JOAQUIN COUNTY PUBLIC HEALTH SE?KICES QIAJ�� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> r (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CXmPMtX In TT"gTNXbI <br /> APPIIOATION IB HEREBY MADE TO THE BAN JOAWM COURY FOR A PERMIT TO CONSTRUCT ANOOR INSTALL THE WOPR OMCRBED. THIS APPIRCATION IB MADE IN COMPUANCE WITH SAN <br /> JOBAMdESC01/NTY DEVELOPMENT MJ✓'�� R-1110 3�ME STANOARPSPS fS AN JqA�OUNTY RIBIJC HEALTH SSEERMEySS..E�N/NI RpN.MpEM/AL�dNSION. `]�-, <br /> Al <br /> y�� J( ,/� C:N/V �/" �VV� Vlh-' LOTBQE204d', <br /> OWNER'S NAME��A D) E/Z1�' ADDIiE66 ' 7N. WeiC e,, <br /> MMMCTOIU �- ADDRESS �J IRCI "�� PHONE <br /> BUS CONTRACTOR ADDRESS —1 IRCI �� PRONE <br /> `TYPE OF SEPTIC WORK: NEW MXTALLATON ❑ REPAnvAOMTRON ❑ DESTRUCTION <br /> MO BEPUC SYSTEM MPIMITI'M IF FVBIRC SEWER IS AVARABLE WITHIN 300 FEET OF BUIU)INO.I PEIC TESTIBI I 1 ROW MANY <br /> AppiaBen <br /> y.MXTAUI TON WRL•ENE: FEBRIEFICE 13COMMERCIAL 0 OTHER 13 <br /> �MM91 OF IRWMO UMTX: IPUMIOER MSEI OF SEDOOMS: NU OF EMPLDYEES: <br /> CHARACTER OF WN.TO A DEPTH OF 2 FEET: PITIBUMP SOIL CHARACTER: WATER TABIE DEPTH <br /> FERIC TANEJOREAXE TMP 0 TYPEIEKO CAPACITY NO.COMPARTMENTS <br /> `REO TTIEATRIEPT RANT 0 DISTANCE TO NEAREAT: WELL FOUNDATION PROPERTY UNE <br /> UFT STATION 0 SITE TYPE OF RUMP SANG OR.SEPARATOR ENCLOSED SYSTEMI <br /> 'EACNNO IMIE ❑ NO.•IENOTM OF IRNEe DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> TLTER BFD OWRTTN usw; H OEYTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY RINE <br /> 1 OUNOM O 1AIDTN IFNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION ROPFRTY UNE <br /> IiDAOE RTX O DEP1H am NUMBER DISTANCE TO IIEAREeT:WELL FOUNDATION RORRTY UNE <br /> :LIMPS OWIDTH EENOTN OEPM DISTANCE TO NEAREST:WELL FOUNDATION P KRTY UNE <br /> NLroiAI MNOX DWIDTH IEIOTH OEPRH DISTANCE TO NIAEST:WELL FOUNDATION PROKRTY IME <br /> I HERESY CERTIFY THAT 1 HAVE P PARED THIS A ATION ANO THAT THE WORK WXL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RUES <br /> NO PEGUTATpNB OF THE SAN JOAOUM COUNTY.HOME OWNER OR MERMD AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT INTHE PERTOIMAME OF THE WOW FORWHICH <br /> 1nS REPAIR 18188UED,I BIINL NOT EMROY ANY PERSON M BUCN A MANNER M TO BECOME SUBJECT TO WORKMAN"B COMPENBATbN UWt OF CAURIIMA.' CONTRACTOR'S MRWO OR <br /> UB{ONTRACTINO SIGNATURE CERTIFIES THE FOU-O W :'1 CERUFY THAT M THE PEWORMAICE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHML EMPLOY RRSDNS SUBJECT M <br /> WORKMAN'S COMPENSATION IAWS O/F/CCAAUUMMIA.-.- THE APRRCANT MUST CALL 24 HOURS IN ADVANCE TOR ALL REQUIRED INSPECTIONS. COMPLFIE DRAWING BELOW. G <br /> TONED X TTT E: LIJ,7 F✓— DATE: /U- /�• - / <br /> PLOT FLAN(DRAW TO SCALE SCALE_ 'to <br /> 1. NAMES OF STREETS OR MADS NEAREST TO OR BOUNDING THE PROPENTY. 4. LOCATION OF ROUSE SEWAGE 011MISML SYSTEM OR P MSM <br /> OUTME OF THE�KRTY.WITH <br /> NS AND NORTH URECTION- <br /> PANSION OF SEWME <br /> MENBONEO OUTLMES AND LOC TA IONOF ALL UM MO ANO PROPOSED STTIUCTURES, S.Lx ATON OF WELUI WITHIN MdU6~ �RFTY FT.ON ^I <br /> INCLUDING COVERED AFE.A8 BMH A8 PATIOS,ORVEWAYS,AND WA S. THE PROPERTY OR ADJOBRNG PRDPEp(Y !".rq _ _ F \_ <br /> OC'r 1 . <br /> FF- <br /> 6 1558 <br /> 9 r/I1190/��.1,e l� <br /> /d o.P e- <br /> 6-4 C. N <br />