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<br /> APPLICATION FOR LIQUID WASTE PERMIT
<br /> JOAQUIN COUNTY PUBLIC HEALTH VRVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (90/1164z)0/116 z)
<br /> (209)458-3420 LL��ii���1
<br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED
<br /> Ic"Iste IN Tripiiwtrl
<br /> APPLICATION If HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO COHSTRIJCr ANDIOR INSTALL THE WOW DESCRIBED, TWO APPLICATION M MADE IN COMPLIANCE WITH SAN
<br /> JOAQUIH COUNTY DEVELOPMENT TITLE,C^F�1APTER 9-1110.3 AND T114E STANDARDS Cf SAN JOAQUIN COUNTY PUBLIC HEALTJH�SEERRVIICES.ENVIRON�M.ENTAL(HEAALT�H(DIVISION,
<br /> JOB ADDRESIMR APNI V T" `d� -1 `rte �+`'• S�tf—vo0 f-r "�W CITY Lo I
<br /> OWNER'SNAME�]A.�t� V�.I- Ick l W1Y1Q�1L ADDRESS /�� PMIE69�7` "q� /
<br /> CONTAACrOR Y1 . ADDRESS -6Y1 [.OR `I LIC/ PHONE36 7'371 I
<br /> BUB CONTRACTOR RESS UCI PHONE
<br /> TYPE OF&Dr"C WORK: NEW INSTALLATION ❑ REFASVADDITIGN ❑ DESTRUCTION 13
<br /> I WO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO,F PERC TEST14 I 1 HOW MANY_____^_^�
<br /> E AvaFb.r�r
<br /> tNSTALLITION WILL 4atVE: RESIDENCE❑ COMMERCIAL, ❑ OTHER❑
<br /> NUMBER OF WINO UNITS: NUMBER OF BEDROOMS: NUMSEt OF EMFLOYEEf:
<br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PRT/SUMP SOL CHARACTER: WATER TABLE DEPTH
<br /> SwITC TAN[UOREASE TRAF ❑TYPEIMFO CAPACITY NO,COMPARTMENTS
<br /> PKQ TREATMENT PLANT❑ DISTANCE To NEAREST: WELL FOUNDATION PROPERTY UNE I
<br /> LIFT STATION 0 SME TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> LEACHING LINE ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> RLTm BED ©WIOTH LENGTH DEPTH DISTANCE TO NEAREST.WELL FOUNDATION PROPERTY LINE
<br /> MOUNDED O WIDTH UNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRUNE
<br /> SEEPAGE PITO 13 DEPTH BT;E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE
<br /> BLIMPS ❑WIDTH LENGTH DEPTH IXSTANCE TO NEAREST:WEN. FOUNDATION—PROPERTY LINE
<br /> DISPOSAL PONDS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> I HEREBY CERTWY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WITH SAN JOAGIAN COUNTY ORDINANCES AND STATE LAWS,AND RULES
<br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SRiNATURRE CERTIFIES THE FOLLOWING,'ICERTIFYTHAT IN THE PEWORMANCE OF THE WOW FOR WIBCH
<br /> TMS PERMIT IS M=,1 SHALL NOT EMPLOY ANY PERSON BL SUCH A MANNER AS TO BECOME SUBJECT TO M14KMWS COMPENSATION LAWS OF CAUPORNSA.' CONTRACTOR?HARING OR
<br /> SUB-CONTRACTING SIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOKS FOR WMCH THIS P'omm IS ISSUED.I SHALL EMPLOY PERSONS SU6NECT TO
<br /> WORKMAN'i COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED I`N/SPECTION& COMPLETE DRAWING ING(BELOW.
<br /> SIGNED X a � _ ..,__, TrrLE: , l`(J• rn�f�l5 GATE: �'F �_ r 1 �"
<br /> PLOT PLAN IORAW TO SCALA SCALE •ie �.••J
<br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT.ON
<br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WAILS. THE PROPERTY OR ADJOINING PROPERTY. L
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