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4PPLICATION FOR LIQUID WASTE PERMIT <br /> S.— JOAQUIN COUNTY PUBLIC HEALTH SERVICES_. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> ` (209) 488-3420 <br /> 11111-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpiBM1 in TriplkBtEl <br /> LIIB'PLICATION IB HEREBY MADE TO THE BAN JOAG M COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WOIK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> "AMIN COUNTY DEVELOPMMENT TITLLECHAPTER 9-11110.3 ANO/THE STAANN/DIUSIS OF SAN JOAOUIN COUNPUBLIC C HEALTH,B{E/1/�{V10EB.ENVIRONMENTAL HEALTH DIVISION. <br /> IB ADDREBSIOR APNE 26-210 <br /> 3 Z, �.Z.fwiY`� /G{� CITY /Vi✓fO LOT MLq'4eo A4* <br /> 1 <br /> PWNER-S NAME <br /> AooREss �i/QtsnCf ( / '/ PHONE /'S �/�� <br /> CONTRACTOR Lh �1.. �- �- ADDRESS lZ/ !- C �� ' S//Y LIC. 'f 27.1:SNE`O /0�- )3V 3 <br /> IB CONTRACTOR ADORERS LCF PHONE <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION L.D REPAIRIADOITION ❑ DESTRUCTION ❑ <br /> O SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200FEET OF BUILDING.) PERO TEBTM 1 I HOW MANY <br /> AooEe.tlen I <br /> (Nit AUJUTON WILL SFRVE: RESIDENCE COMMERCIAL 13OTHER [IAN <br /> GOR OF LIVING UM / <br /> TS: 1 NUMBER OF BEDROOMS: �\ NUMBER OF EMPLOYEES: <br /> M_I <br /> 1 TFR OF 601E TO A DEPTH OF J FEET 4iA/L14rR_ gTle(VMP SOIL CHARACTER Tr~y�� TER TABLE OERN � �J T1 <br /> (t ESRC TA OREACF TRAP ❑TYPEMFO 4[T11CI � '5t"-FJ.T CAPACITY / Z-__%� NO COMPARTMENTS'PKO <br /> EATMENT PLANT ❑ DISTANCE TO NEARUT' WELL ^HCl— FOUNDATION ,�.L S F PTOPERTY LINE . () <br /> LIFT STATION❑�SII$E \ TYPE OF-EPUMP BAND OIL SEPARATOR(ENCLOSED SYBTEMI <br /> e 'T <br /> ACHING UNE �!- HO. LENGTH OF LINER'(- y0�/' "'i DISTANCE TO NEAREST:WELLySQ � FOUNDATION 2 S' RmorrRTY UNE <SCJ r <br /> FILTER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PTOPERTY LINE <br /> DUNDED ❑rWIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> �EPAOE Rp <br /> TS I DEPTH 2 812E 14 W" NUMBER DISTANCE TO NEAREST:WELL E/O tO ' FOUNDATION 35I PROPERTY UNE 10KJ <br /> BUMPS ❑MOTH LENGTH OEM" DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> —'9nSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTV UHE <br /> 'EMERY CERTIFY THAT 1 HAVE PREPARED THIS APF CAT N AHO THAT THE WORK WILL BE DONE M ACCORDANCE WREN BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERT71THAT IN THE PERFORMANCE OF THE WORK FORVYIIC14 <br /> TNIB IS ISSUED.I SHAOY ANY PERSO SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> LL <br /> IR- M CTMO NATU ERIE HE FOLLOW( CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSUNS SUBJECT TO <br /> �OPK MAN'S O PENS IO WS OF C �R...� ANT MUST CALL 24 HOW IN ADV ANC E FOR ALL RE RED INSMIGONG. COMPLETE DRA NOBTLOW� <br /> SIGN % \i �._ ``1l�ppp(( �I Ci Z <br /> 1 PLOT PLAN IDRAW TO SCALE(SCALE_—Ie <br /> 1. NAMES OF STRE SOP AOS NEAREST TO OR BOUNDING THE FRDPERTY. 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR PADMSEU <br /> 2. OUTLINE OF THE PiE5K NRH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> - DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 1NCLUDINO COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAURB. THE PROPERTY OR ADJOINING PRIOPEnTV. <br /> 1, I <br /> ll <br /> rtri-LtQil //crcS� <br /> .. ........._-..— \o <br /> r-AYMIE>i T' <br />