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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)466.3420 <br /> ROD•REFURDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Compkts In TripOeatel <br /> ' APPLICATION IS HERESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCREED.THIS APPLICATION 18 MADE IN COMPLIANCE VMH BAN <br /> JOAOUN COUNTY DEVELOPMENT'TITLE,CHAPTER 9-1I I O,3 AND THE STANDARDS OF VAN JOAOUIN COUNTY PUBLIC HEALTH SERVICEB.ENVIRONMENTAL HEALTH DIVISION. ,/�L <br /> JOB AQOAE6BAJR APNA 4T CIIY��� i �jC/OT BREI <br /> OWNER'S NAME ] J]� L' vi -S AD... PONE-3:J Lp��d 8 r® <br /> ' CONTRACTOR 4' 10 y17 11 �n N �LI�El6 i"I t ADDRESS i UCA PIpNE �I C <br /> SUS CONTRACTOR ADDRESS (JCR RHONE <br /> T'/P[OF SEPTIC WORK: NEW INSTALLATION❑ REPARVADDRTION' DESTRUCTION❑ <br /> ' (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BULDRH0.) POIC TESTI.)I 1 NOW MANY <br /> App#m9ion 3 <br /> INSTALLATION WILL SERVE: RESIDENCE a COMMERCIALO LATHER 13 <br /> KNEER OF LMNO UNITS: 1 NUMBER OF BEDROOMS:NUMBER OF SMPLOYUSI: <br /> CHARACTER OF SOIL TO A DMH OF 3 FEET:�'^�'y��PITISUMP SOIL CHARACTER: 4: WATER TABLE DEPTH��' <br /> SDRC TANKIORFASE TRAP ® Try 6 �o O NO.COMPARTMENTS .L. <br /> ' PKO TREATMENT RA <br /> NT <br /> I 13 INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE ` <br /> UFT STATION 11T•SRME TYPE OF PUMP e�•y `SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE 13 NO.a LENGTH OF LINES I m-,( /� /®®� DISTANCE TO NEAREST:WEId-5-0 FOUNDATION PROPERTY UNE m(V <br /> FILTER BED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> ' MOUNDED ❑VNOTH LENGTH �s DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PTPRIS D DESRE�`Tj.—..NUMBER DISTANCE TO N-aARm;WTELW,—LaFOUNDATION PROPERTY UNE <br /> OLWPS 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE al` <br /> DISPOSAL PONDS ®WIDTH LENGTH DEFT" DISTANCE TO NEAREST:WELL FOUNOATTON PROPERTY UNE ' <br /> ' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> AND REGULATIONS OF THE GAN JOAQUIN COUNTY.HOME OWNER OR LICENSED ADENT'a SIGNATURE CERTIFIES THE FOLLOVANG:'1CERTIFY THAT IN THE PERFORMANCE OPTHEWORK PORWHICH <br /> THIS PERMIT IB ISSUED,I @HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.*CONTRACTOR'S HIM OR <br /> SUB-CONTRACTING MNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION <br /> /-L/AWS OF C/p�LJPORNIA. THE AAPYMOCANT MUEY CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION®.COMPLETE DRAWING BELOW. <br /> SIGNED X U.e.R,Pi9 LC, a1/ ° /Ld7•�\ TATLE:�•6 6� G N. ®U` DATE: <br /> PLOT PLAN(DRAW TO SCALER SCALE <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE 0030SAL SYSTEM OR PMPOSED ry9� <br /> 2.OUTLINE OFR <br /> E PFWPEFRY,WTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY6TEM8. <br /> 3.DIMENSIONED OUTUNEF,ANO LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. E.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> ' INCL.UDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WAIKB. •.- THE PROFRfIY OR ADJOINING PROPERTY. <br /> ....>....E....»T... .....; <br /> .....:+.....L.....>...... ....::......:.... ........... ............. ............. <br /> .........I <br /> •_.._:�...•.....:. <br /> ..._......._...<..._. ..._;...s........._.......... <br /> E <br /> :.... ......:.....:............:......•.............I...._..... .....«.....a 14r;...... <br /> ..:......: <br /> _€.........�:� w .... <br /> i <br /> 1 ... ..... ......'- <br /> NJ i i 1 <br /> ......;..�... a......g.....o.................. <br /> 5.......:.. <br /> ...5...,..o......f_.....1 <br /> :... <br /> E , <br /> Ii ........... <br /> .........................................b......_.....a......;......a.........a a....._....p - <br /> - - j .... ...................... ....... <br /> ........................ <br /> .......... <br /> S <br /> } <br /> .......... <br /> '. L <br /> A <br /> l,rT <br /> .. <br /> i i E i i S ............ ....... <br /> -..:....,a.-=••j...... <br /> ....E....»a._......_..a......:......a......;._...........;......c...... ......... <br /> ��Ml!lI• <br /> .nT�t <br /> i�' .................. <br /> ...... _._4. <br /> :....... ........°.... .................. ..... <br /> _. .... <br /> EN PUBUC�EAL7H gUDNTY <br /> FOR DEPARTMENT USE ONLY <br /> q/pypLIC TION ACCEPTED DY �' P DATE: � � ARA: <br /> (TgPI1KA R SUMP INSPECTION DATE /' %L IN CT N BY OA <br /> ' lllllADD1DDIDITION-COMMENTS: <br /> aCcnuNTrtdO ONI.v: AID# FhCa <br /> ' LDE gFE-EINFOAMOUNT NMI-TED HECK0 ASH RECEIVED BY DATE $N/T"T NUMBER INVOICE B <br /> ' Pub.Health Sorv.-Enviro.174(3MG) <br />