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APPLICATIO' R LIQUID WASTE PERMIT <br /> LJ��{Cf SAN JOENVIRONMEPUBLIC SERVICES <br /> HEALTH <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 �% Z <br /> l'1 r (209)468-3420g�- �(" ✓f <br /> NON REFURDABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pe( , <br /> 1Ce1npl4u In TRblkaul <br /> APPMATON IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONBTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IH MADE IN COMPLIANCE WITH SAN <br /> JOAOVIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAOVIN COUNTY PVRLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDRESSOR AM# - CITY LOT SIZE <br /> ++OWNER'S NAME ADDRESS - PNONE <br /> CONTRACTOR ADDRESS LCI PHONE <br /> SUB CONTRACTOR ADDRE66 UCF PHONE <br /> f61C TESTIS 1 11gW ARMY <br /> TYPE OF HETC WORK. NM'MSTALIATRON❑ RETANVADOITION❑ OUT—"—❑ <br /> 'IND SEPTIC SYSTEM PERAUT TED IF PUSU6'EIN <br /> C ER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.1 <br /> TI1 <br /> Appllutlen <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ <br /> NUMSBU OF UVINO UMTS: NUMBER OF EEDROOMS NUMSER OF EMMOYEL: <br /> —HAMCTER OF SOIL TO A DEPTH OF J FLET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANK'ORE"IF TRAP Cl TYPE/M'0 CAPACITY NO.COMPARTMENTS <br /> PKU TREATMENT PUNT❑ DISTANCE TO NEAAUT: WELL FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> IUCMNG UNE ❑ NO.S LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH- DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH D,STANCETo NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEYAOE Is ❑DEPTH SIZE NUMSER DISTANCE TO NEAREST:WELL FOUHDATION PROPERTY UNE <br /> ELM" ❑WMTN LENGTH DEPTH DISTANCE TO NEAREST:WEll FOUNDATION POPEFT UNE <br /> —'s-SAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPY ATON AND THAT THE WORK WILL BE DONE W ACCORDANCE WIN SAN JOAOUIN COUNTY ORDINANCES AND SLATE LAWS,ANO RULES <br /> MNDREGVLA HIS OF THE BAN JOAOUN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWSNG:'I CERTIFY THAT.THE PERI`ORIAANCE OF THE WORK FOR WHICH <br /> THIS PERM FT NS ISSUED.1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME WWECT TO WONCMAN't COMPENSATION LAWS OF CAlJFO1MA.' COM RACTOR'S HIRINSUBJECT <br /> OR <br /> BUB{ONTRACTINO SIGNATURE CERTIFIES THE FOLLOWMO:'1 CERTIFY THAT IN THE PEWORm ANCE OF THE WORK FOR WHICH THIS PERMIT IH Ia SUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> NOP(MNI't COMPENSATION LAWS OF CALIFORNIA,' THE APPIICANT MUST CALL 24 MOLARS IN ADVANCE FOR ALL 11IUlARED INSPECTIONS. COMPIE'IE DRAWING SFLOW. <br /> TITLE DATE <br /> P.NED X <br /> PLOT RAN(DRAW TO SCALE)SCALE <br /> 1,NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDMO THE INOPERTY. IRA. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> "I.OUTLJNE OF THE POPERTY.WITH DNAENSt .S AND NORTH DIRECTION. EILPA TION F TELL.W THINDISPRAI SYSTEMS. <br /> J. DIMENSIONED OUTLNFS AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUIRES, S.LOCATION OF WELLS DNI" RADIUS OF ONE HUNDRED FIFTY R.ON <br /> INCLUDINO COVERED MEAS SUCH AS PATIOa,DRIVEWAYS,AND WALXS. — THE PROPERTY OR ADJOMINO PROPERTY. <br /> I <br /> L f <br /> 1 <br /> _ l <br /> I •. I <br /> � I <br /> �J <br /> - PAYMENT <br /> !. l <br /> RECEIVED <br /> NOV 81999 �c <br /> - SAN JOAQVi'l C.'JIJNTY <br /> PUSUC-HEALTH SERVICES �- <br /> nNVIRONMENTAL HEALTH ON1340 �— <br /> _._ _ <br /> I FOR DWAPTMENT USE ONLY N O <br /> DATEATEA: <br /> e.•PPUCAIION ACCEPTED By - '�f •1 1` IL'`• . r'4' / .. ` <br /> TANK.PR OR BUMP M6PECTIOH BY <br /> DATE [ / FINAL INSPECTION BY DATE / / <br /> ADDITIONAL COMMENTS: <br /> ACCOUNRNO ONLY: AIDE TACT <br /> L. <br /> K CODE FET INTO AMOUNT RANI ED CHECKER' H 11ECFNED ST DATE S11 f F9S.ST NISNB9t IIFVOICES <br /> ,1 <br /> Put.Health SeN,-En-0,174(3/96) <br />