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,*,e APPLICATION FOR LIQUID WASTE PERMIT ©�S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION '^ <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 �F� <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED V <br /> N.BgpltltB In Trlpl'iEBttll <br /> APPLCATION IB HEREBY MADE TO THE SAN"AMIN COUNTY FOR A PERAIT TO CONSTRUCT ANDOR INSTALL THE WORK DESCRIBED. THIS APPMATION 18 MADE IN COMPLIANCE AN <br /> JOAWM CO,DEVELOPMENT TALE CHAPFER 0-1110.3 AND THE SAIANDAR08 OF SAN JOAOUIN COUNTY MOM HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR A/M, 7 ?.+ZCOA JACK 'T1OW 5;I ISO A 0 �,F��T{{�l� Cm ♦�1� C/AJ t``�)Pp / i(fy�LOT azE�QL. <br /> OWHER'BNww l IM1/!l IIFje Aj� /�( 1141213 I0lUSI AlORESB 3a(0 SIIEILIV(l< <br /> CONTRACTOR L JW IV L R IIDD11Eso �� CfA(�L \\ Mo FHow <br /> SUS CONTRACTOR ADDRESS SCE RgNE <br /> TYPE OF EE9TIC WORK: NEW INSTALLATION ❑ 11EPNVADDITgN Cl DESTRUCTION <br /> INO SEPTIC SYSTEM PEMIRTED IF PUSLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BURDNLO.1 PENC TESTHI I 1 HOW MANY <br /> ApPYstlon <br /> INSTALLATION WILL'ENE' RESIDENCE❑ COMMERCIAL ❑ OTHER❑ <br /> NUMBER OF UVINO UNITS:_ NUMBER OF BEDROOMS: NUMBER OF WMOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF J FEET: W/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANN/OIEASE TRAP ❑T/PENAPO CMACTTV NO.COMPARTMENTS <br /> PEO TREATMENT RANT❑ DISTANCE TO NEMEBT: WELL FOUNDATION FnomR LINE <br /> UFT STATION❑ SIZE TYPE OF NMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACMNO UNE ❑ NO.B LENGTH OF LINES D18TANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> _ FILTER BED ❑MOTN LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUWATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEVAOE RTS ❑DEPTH S E NUMBER DISTANCE TO NEAPEST:WELL FOUNDATION PROPERTY LME <br /> SUIHM ❑MOTH LENGTH DEPTH DISTANCE TO NEAPS IO:WELL FOUNOATpN PROPERTY IME <br /> DISPOSAL MNOS ❑VADTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> - <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN"AWN COUNTY ORDINANCES AND STATE LAWS,AND RUUFS <br /> AND ,OULATS A,OF THE BILI MACRON COUNTY.HOME OWNERDAMMSED AGENT'S SIGNATURE CARTNIES THE FOLLOWIM:'I CERRFYTHAT INTHEPEROPMANCE OF THEWOMM"WHICH <br /> TINS PERMR IS ISSUED.1 SNALL NOT EMPLOY ANY PEABON IN SUCH A MANNER AB TO BECOME BUBIECT TO WOIKMAN'S COMPENBATgN UWB OF CAUFORRA.' CONTRACTOR'S RRNG OR <br /> SUB{ONTRACTIHO SIGNATUIR CERT01EB THE FOLLOWING:'I CERTIFY THAT IN THE PER D MANCE OF THE WDW FOR WHICH THIS PERMR IS ISSUED,1 SHALL EMMOY PERSONS SUBJECT TO <br /> WOIWMAN'S COMPENSATION LAWS OF CALIFORNIA.' TIIE APPLICANT MUST CALL N HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWIND SELOW. <br /> SIGNEDx (�"l llua, ( j, GVIC{qTRLL1`�-OP. �7fI -DATE: <br /> ROT RAN MRAW TO SCALL)SCALE_ 'In <br /> 1. NAMES OF STREE1`8 OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. tl. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED L <br /> 2, OUTLINE OF THE RROEFRTY.WITH DIMENSIONS AND NORTH UIRCTION. E%PA1810N OF SEWAGE DISPOSAL 8YSTEM9. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON (� <br /> MCLUDING COVERED MEAS OWN AS PATIOS,DRVEWAYB,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. U <br /> ? ` c <br /> ,"It �; N ff <br /> L"� wNilL t'N.T.MEN '. <br /> 57FICEIVED <br /> JUI L 2:0109. <br /> '... - PUMIC'Hi£ATTTN FTDRwAo <br />