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APPLICATION FOR UOUID WASTE PERMIT <br /> SAty JOAQUIN COUNTY PUBLIC HEALTH SrAVICES rA <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 9E <br /> NON-REFUNDABLE PERMIT EXPIRES t YFAR FROM DATE ISSUED <br /> IC¢mRMb In Tr plieabl <br /> APRIOAMN 18 HERESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAJR INSTALL THE MOR(KE RI ED. TNS APPLICATION It MADE M COMPLIANCE WITH SAN <br /> - JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER/8-111'10.3 rAM THEIST-AMAA?RDS OF BAN JOAOUIN COUNTY PUBLIC HEALTHTSEMMES,ENVMIDNMENTAL HEALTH OMMN. <br /> JOB AODRESS/OR AMI y 76 w Q' ! n u( L/-rCj 1T- �d_ Cm ''- h o t-n td✓l LOT SIZE I AG0 f)146V 1-Xy <br /> OWNER'S NAME #I CL M� aberta ADDPE99 /� QI -X �/ I 7O/1 ✓I T017 F.mw 2-9 'IJJ, <br /> COMPACTOR_ O t/✓ �I - ADDRESS IICe FIMNE <br /> SUR CONT C OR ADDRESS UC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INtTwLLATroM MFlllNllADdT10M ❑ DiE TRIICNON ❑ <br /> MO SEPTIC SYSTEM PERMITTED IF MSM SEWER I9 AVAILABLE WITHIN 200 FEET OF BUILDING.) P91C TESTI.)1 1 NOW MANY <br /> APFIsSen <br /> INSTALLATION WILL SERVE' RESIDENCE 11L 11COMMERCIAOTHER 11i� <br /> NIMBFA D LMNO IMTt: / MLMBER OF BEDROOMS: 3 NUNMER OF fFAFLOYFFS (D <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FLET: PR/-SeLIIMMP SOM.CHAR EP: WATER TABLE DEPTH <br /> SEF"M TAHKATREAtE TRAP ❑TYPEJMFO CO✓14IN LI CAPACITY 1 /200 NO.COMPARTMEM6 <br /> -PRO TPEATMETIT DISTANCE TO NEAREST: WELL FOUNDATION RKIF`ERTY UNE �! <br /> LIFT STAMM T�FF/L.IC.-�E TYPE OF PUMP ..ff SAND OB.SEPARATOR RNCLOSED SYSTEM) ? <br /> LFACNNO UNE NO F LIVES I yQ DISTANCE TO NEAREST:WELL So E'MUMAM /Q FMFERTV UNE 5 F <br /> FILTER RM D WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION FMFERTY LME <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAPEST:WELL FOUNDAMIN PROPERTY UTNE <br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDAMN FKOFERTY LANE <br /> SLMFS ❑WROTH UENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDAMIN FMPERTY LINE (\ <br /> MSPOSAL PONDS ❑WIDTH UENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P1IDPEATY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLIOATION ANO THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAODN COVNIY OPDINANCES AND STATE LAWS,AND 1111LES <br /> AND REOULATM)NS OF THE SIU)JOADIIN COUNEY.IOMEOWNEA ORLICENSED AOEM'S SONATURE CFATMRB THE FOLLOMINO:'ICFATIFYTHATNTFIEFERFOMIANCEOFTIEW M1 RWMCH c <br /> THIS M4 N ISWED.1 SHALL NOT EMPLOY ANY PERMN M SUCH A MANNER AS TO SECOME WSFECT TO WOMMM'S COMPENMTIOH"A OF CALAFOPMA.- CONTRACTOR'S HIFIM OR <br /> SUB-CONTRACTING SIGNATURE CERFIFRS THE FOLLOWING:1 CERTIFY THAT IN THE FTRFE MAANCE OF THE WOR(FOR WHICH THIS PERMIT It ISSUED.1 SHAH-EMPLOY PERSONS SU6)ECT TO <br /> W OMMAN'6 C AHSAT LA OF C✓/A/L/1AF�ORNMA.' TH APPLICANT MUST CALL M HOUNUI IN ADVANCE FOR�A+LLIR <br /> L REOUM IM804MMNS. COMRETE DRAWING'BELOW. <br /> SIGNED X \ / I TITLE: V W 'F Y1 DATE' l 1 a 1 Cl 7 <br /> ROT RAN IDRAW TO SCALE)SCALE_ e <br /> 1. NAMES OF STREETS OR MADS NEAFIEST TO OR SOUNDING THE RRORRTY. 4. LOCAMN OF HOUSE SEWAGE MSFO6K SYSTEM OR IMPOSED <br /> 2. OURNE OF THE PMFERTY,WITH ENMENS10NS ANO MONTH DIRECTION. EXPAHMN OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AM LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDIM COVERED MREAB SUCH AS PATIOS,DISVEWAYS.ANO WALK& THE PIOPERTY OR ADJOIMHO PMPERfY. <br /> 1 20 0w 0 01 <br /> _ .._.. <br /> L <br /> 3 11oaF7- <br /> 6 PAYMENT <br /> rIECEIVED _ <br /> o Fr Nov 18 1997 <br /> � 1✓•L( � ..BAN JOAQUIN COUNTY <br /> .,, <br /> PUBLIC HEALTH SERVICES <br /> uulTu nnn¢Inu <br />