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APPLICATION FOR LIQUID WASTE PERMIT <br />or p'1" SATraOAQUIN COUNTY PUBLIC HEALTH L—Y ICES <br />Gej 1 ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468.3420 / <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Compute In Trjolkstel / <br />A'RICATION 18 HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE W W DESCRIBED. THIS AP'LICATION 18 MADE IN COMPLIANCE WITH BAN <br />JOAWIN COUNTY DEVELOPMENT TRIS. <br />_ N^�LEfl 8-1177-T HE /�DA ��OAOUIN� RTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTHDIVISION. <br />Joe AOEREttIon ANE 94 <br />crry "5C3IW 'LOT SIZE Ij { l <br />ONMER'B NAME PVOzy F 7 C (!-,nA bi ADDRESS <br />CONTMCTOn SIrL f` ADDRESS me PHONE <br />SUBCONTRACTOR ADDRESS <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ PREPA UADDLTION ❑ DESTRUCTION ❑ <br />ONO SEPTIC SYSTEM PERMITTED IF PUBLIC 6EMD910 AVAILABLE WITHIN 200 FEET OF BUILDING.) MC TEETPI I 1 HOW MANY <br />- ' Yom. I/ AppEostlan <br />INSTALLATION WILL SERVE: RESIDENCy�y COMMERCIAL ❑ OTHER 11NUMBER OF "No UNTE:_L NUMBER` OF BEDROOMS: NUMBER OF EMPLOYM: <br />CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTISUMP SOIL CHARACTER: WATER TABLE DEPTH <br />SFTIC TANIVOIEASE TMP ❑ TYPE M CAPACITY NO. COMPARTMENTS <br />PILO TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />— <br />UFT STATION ❑ SIZE TVR OF PUMPSAND ORI, SEPARATOR (ENCLOSED SYSTEM�TMI <br />Ii <br />LEACHING ONE NO. a LENGTH OF ONES � 1 <br />DISTANCETONEEST:WELL! L� / FOUNDAN �O MOPERTY LINE zCo 4 <br />� 4O J��T� NI <br />MTM SED ❑ WROTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION P10PERTY UNE <br />MOUNDED y❑� WIDTH <br />^ LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION c PROPERTY UNE <br />SEGIAGE PIT& M1]I DEPT" LS SIZE— y <br />NUMBER ) DISTANCE TO NEAREST: %VEI-L MUNDAT10NO I Momma V UNE -1 Cc ) <br />SURAPS ❑ WROTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION MOPEOTY UNE <br />DNPOSAL FONDS ❑ WROTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />— <br />I HEREBY CERTIFY THAT 1 HAVE MEPARM THIS A ATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MEN BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND RULES <br />AND REGULATIONS OF THE SAN JOAOVIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MUOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PPafi IB ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'@ COMPENSATION "We OF CALIFORNIA.' CONTRACTOR'S HI SNO OR <br />SUB -CONTRACTING SI(TNATURE CERTIFIES THE FOLLOMNO-'I CERTIFY THAT IN TI HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br />MMMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTORS. COMPLETE DRAWING BROW. <br />SIGNED EQ✓If TITLEOry N cE- DATE / fy1 <br />E� <br />PLOT RAN (DRAW TO SCALE) @CAE - le <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY. WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RAD USS F ONE HUNDRED FIFTY T. ON .. <br />�0 � <br />fe 7 <br />711 <br />AFtICATION ACCEPTED BY <br />TAN< R SUMP MSKCT�M114 <br />ADDITIONAL COMMENTS: <br />FEB 2 6 1999 <br />f rn O <br />/'� � „wlgcidk ENL! Tt n�ri.I r <br />�, HF, t 'VICES <br />OEPARTMENI USE ONLY / / 1 i � A11FA: ( <br />DATE: l/ 7 <br />TE 1Z I NAL INSPECTION 017-1 I DATE/'In <br />-rT <br />ACCOURTTNQ ONLY: I ADE <br />I FAC@ <br />CHEC ASH <br />RECEIVED BY <br />DATE <br />M IPERMIT NUMBER <br />.—CE, <br />PE CODE EEE INFO AMOUNT REMITTED <br />Pub. Health Sew, - Enviro. 17744y(3,/96)) L/.-{'- S ( l � L� — (d y 4'/ <br />