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APPLICATI— FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIr .NTY PUBLIC HEALTH SERVICES `%nor <br /> a a' ENVI 10 ENTAL HEALTH DIVISION <br /> P.O.BOX 388, 446 N.SAN JOAOUIN ST.,STOCKTON,CA 96201-0388 <br /> 12091 4683420 <br /> II. MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (U.PWU M TTTUubI <br /> %RPUCATNN IS HERESY MAGE TO THE SAN'.AMIN COVNFY FOX A PEWJFI TO CONSTRUCT ANDAIR INSTALL THE MW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WIT.SAN <br /> -AGUIN COUNTY MYELO✓RNSUff1 TREE,,,CHAPTER&l 110.3 ANO THE <br /> -STANDARDS OF SAN J�/O/�AMIN(COUNTY RIBIY HEALTH SEAMED,ENVIHOMFNTM-HEALTH DIMMN. /L'/�� <br /> �1ADDRESBpR A((PN��E//��'9� 0,2P�/�vG��]/��( ,�ck t-,"e l rJ&D CRY Rj pc>hj cYT LET. 2 Aeour. <br /> JWNEH'BNAME�ij„'J'Pk&3 T' e J ADDRESS 'K�LAF)�� [y v1PNOE �J <br /> :ONTXACTDX l/E/P'L Cr'�L %NLG <br /> ADDRESS /Z u k\LJTrON L�v� IjO4 4 / VgpNE Ey23.658y <br /> y�CONTRATM. AMESS LIC{ ggNE <br /> TYPE OF SEPTIC WOE: MEWINSTBuLAm.❑ EPNB/AptlTION OFETIIUCTxFm <br /> NO SEPTIC SYSTEM PEWIRTED IF PUSIK�SEWER IS AVAILABLE WTMIN 2.FEET OF BU..I.O., Pp1C TFITBI I I NOW MARY <br /> APFMSNp 1 <br /> IAWTIOX WILL{HIVE: RESIDENCE 21'COMMFACIAL❑ OTHER❑ <br /> RRBEX OF WIXO U.S: I N..OF_Ftl%OOM&:_ M NS.OF LMFIpYFF1; <br /> :HAXACTpI OF SOIL TO A OEPTH OF S FEET: PTT/BUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> -DTIC TANE/ORFABE TRAP ❑TYFFIMFO f CAPACITY NO.COMPARTMENTS <br /> I TREATMENT RANT O tliTAWE TO HFMOT. WELL FOUNDATION PROETMY LINE <br /> y IST STATION 0 SQE TYFE OFJPuMPP �y BAND DL SEPARATOR IEWUOSED SYSTEM)�T <br /> SACNMG MME OrNO.A ISMTH OF ME. I,VJ CY CII DSTACETONEAEST:WFEL AC.OI FOUNDATION_ UT PIRE YMNE 2G/ Vh <br /> ALTER SED ❑WIDTH LENGTH DEPTH, DISTANCE TO NEAEST:WELL FOUNDATION PROPERTY LINE <br /> IWED ❑WIDTH LENGTH MPTH DISTANCE TO NEAREST:W}21 FOUNDATION PROPERTY LINE <br /> SS"PAGE MTB ❑OEFT. 8I NUMBER-DISTANCE M NEAREST:WELL FOUNDATION P PERTY UNE- <br /> I.P. ❑ OTX LENpTH DEPTH MITANCENEAREST:WIII FOUNDATION PROPERTY E <br /> MSPoeA PoNOi ❑MIT) IFHGTN DEPTH dSTAXCEM TO NEAREST:WEIl WMNOATION PROPERTY ME <br /> — <br /> c <br /> RENY CERTIFY THAT I HAVE PREPARED THIS AP ATION AO THAT THE WOE WILL BE DONE IN ACCO U AWF WITH SAN JOAW W COUNTY ORDINANCES AD STATE LAWS.AND RDE_ <br /> )PEGULATIONB A OFTHESMAGUINCOUNTY.HOMEONNERORMCENSEO AGENT'S SIGNATURE CERTIPESTHEFOLLOYAM;-ICEFTYTHATINTHE PIYOWAWE OF THEmw FORNMICH <br /> M!.PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY TFReON W SMH A MANNER AS TO BECOME SUBJER TO MAKMA'B COMPENSATION LAWS OF CAUFOWBA• CONTRACTOR'S HIS.OR <br /> MISIMANS COING SIGNATURE MPENSAT N LAWS OF CALIFORNIA XfNE FIES THE •lAPP1CAT MUSTIFY THAT IN THECALL AINIW ADVANCE FOR ALL EOMREOTI IS PIERNIFT 18 NSHCTIOE.IC COMPLETE DEWING MOW. BWBJECT TO <br /> rv[D% TIRE: GATE. <br /> PDT RAH IOMW TO SCALE)SCALE <br /> M <br /> 1, NAMES OF STREETS OR 110AO8 NEAREST TO OR BOUNDING THE PROPERTY.. 4.LOCATION OF HOMSE SEWAGE DISP)BA SYSTEM OR PROPOSEDUL TMNE OF THE PROPRTY,WITH DIMENSIONS MO NORTH REES <br /> CTION. PANSION OF SEWAGE D MSAJ-SYSTEMS. <br /> Ol W WlOMEO OUTLINES MO LOCATION OF A. ETUSTMIO AND PROPOSED STRUCNE6. S.LOCATION OF WEMJ VRTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> H< <br /> wdNO CO VEER A AS SUCH A PATS....AY.,AO WAILS. THE PROPERTY OA AO LHNINO PROPERTY. <br /> 11 J <br /> y1 <br /> ,4cp <br /> PAYMENT <br /> or 7 7 +9Q,4 <br /> Q- SAN J0A0 UIN CCLIN Y <br /> Pl•t3LIC HFA• IH SFII� 'LS <br /> f JV6i0iJNlClir <br /> JPvzk Tc/u.L LROAlJ <br /> FOR DEPARTMENT ME ONLY r.- <br /> `'UCATION ACCEPTED BY • DATE:�,O I�TiI; <br /> ^_I /0 qqq AREA:_'-' L„Q_ <br /> TAM.PR OR SUMP INSPCTIONW y / / DATE I I FINAL WSSPCTIONN BY /✓Yr OATF J� I / l 9Tf <br /> ATONAL 1 <br /> COMMENTS: ( /r 'K I• • "� /F iT , l /•�'/bb <br /> PLATE 11, Page 9 of 16 <br /> STIRS ONLY: NO/RSB �7FAC/ <br /> FEE INFO I M10UMT..TTED CX /CASH ECDVED BY DATE M/FWNT NUMeMI INVOICE• <br /> N„ 114 0-a-) <br />