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APPLICATION FOR LIBUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 468-3420 <br /> NOWNEFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete iA Triplicate) <br /> d UCATION IS HEREBY MAGE TO THE SAN IOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORIC DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> OAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY FUSUC HEALTH SERVICES,ENVIRONMENTAL HEALTH gNSION. <br /> OB ADDRESSAOR API! / / / !%- ,- (-.t _ <�' <br /> �' CITY LOT LOT SIZE lJ - <br /> wNER'S NAME✓/.iC/./ /-�.:i�i' .>!.•/::.i ADDRESS/ i �l`. ,i<.� �t� r /I'- !'. <br /> PHONE <br /> r 'i •✓ / ' <br /> ONTRACTOR /'•- F <br /> ADDRESS ' :�.` �. /h Y I (• UCl PHONE t <br /> JB CONTRACTOR ADORESS LIC/ PHONE <br /> IPE OF SEPTIC WORK: NEW INSTaLLANON ❑ RADgTION,g DESTRUCTION ❑ <br /> 0 AMC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUILDING.) PBIC TESTI)( 1 HOW MANY <br /> { AppNwtion l <br /> sTAWTWILL ON SFRVE RESIOENCE��e�, <br /> . .I_ COMMERCIAL ❑ OTHER ❑ <br /> AW191 OF LINNG UNITa:�_ NIIMBBI OfP6EOR006fi{: '.JC NUUe91 OF EMILOYEEt: <br /> IARACTER OF SOIL TO A DEPTH OF O FEET SOIL CHARACTER: WATER TABLE DEPTH <br /> PTC TANKIOREASE TRA, ❑TYPEIMFG �y CAPACRy NO.COMPIIHTMEMB \ <br /> G TREATMENT PLANT 11DISTANCE TO NEAREAT: WELL `J FOUNDATION PROPERTY UNE <br /> UFT STATION❑ SIZE TYPE OF PUMP T BAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> ACHING LINE A LENGTH OF UNEB / <br /> �NO. _ fL' DISTANCE TO NEAREST:WELL � C�� FOUNDATION %/- PROPERTY UNE <br /> TER am ❑1410TH LENGTH DEPTH OISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE (� <br /> IUNOED - E3ICWELL.WTH LENGTH OEM DISTANCE TO NEAREST:WEFOUNDATION PROPERTY UNE <br /> FPAOE RTS DEPTH �(j / SaE _NUMBED DISTANCE TO NEAREST:WELL // G MUNOATCN i/ PROPERTY LINE <br /> MPS ❑WIDTH LENGTH / <br /> DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERry UNE <br /> :POSAL PONDS ❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION FNOPERTY LINE <br /> Z <br /> :REBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE CONE W ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE(AWS,AND RULES � <br /> O REGULATIONS OFTHESAN"AWm COUNTY.HOME OWNERORLICENSEDAGENT'S SIGNATURE CERTIFIESTHEFOLLOWING:')CERTIFYTHAT INTHE FEHM MANCE OFTHEwow FORWNIOH <br /> 5 PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON W SUCH A MARINER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> 'CONTRACTING SIGNATURE CERTIFIES THE FOUDWINO:'I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> 'WMAN'S COMFENSATION LAWS OF CALIFORNIA.' THE APPIKANT MUST CALL 24 Mum,IN ADVANCE FOIL ALL IIEOLIIRED INSPECTONf. COMPLETE DRAWING BELOW. <br /> /f `_ TITLE: I'� �/, J N �y <br /> DATE: = L'� <br /> PLOT PIAN(DRAW TO SCALE(SCALE 'I. <br /> 4AMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> )UTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> AMENSIONED OUTUNES AND LOCATION OF ALL EXISTNAT AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 'ICLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALXS. THE PROPERTY OR ADJOINING PTgPERTY. <br /> PAYMENT i <br /> RECEIVE <br /> DEC 8 199 <br /> SAN JOAQUIN COUNTY <br /> PUI3LIC H£ALTM SERVIYaS <br /> NVtRi3NMENTAI H',EAL11I uI L,!U-i J <br />