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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICamplats in Tripkab) <br /> APPLICATION IB HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE W COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TIT F,CHAPTFA 9-1110.3 AND THE STANDAMS OF SAN JOAOUIN COUNTY PUBLIC HEALTH S RVICES,ENVINDNMFNfK HEALTH DIVISION. <br /> JOB ADDRESSOR APWJ CITY L�� ,,./}��- <br /> • �A^'���' LOTSIZEJ T/vim <br /> OWNER'S NAME TA�ADDRESS I Z y2 <br /> COML- (:L PHONFS�^AX7�GbS�( <br /> NTRACTOR Dol • --FFIUDoxbs_[�f�l ('Al PHGNE��LQ�$ <br /> SUBCONTRACTOR ADDRESS IJCJ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTA Mll ❑ RVAMIAD N DFiTRmmN <br /> ONO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVARABIF WITHIN 200 FEET OF BUILDING) PEFC TESTI.)1 I NOW MANY <br /> Appleetbn I <br /> INSTAL ATION WILL SERVE. RESIDENCEIK COMMERCIAL❑ OTHER [] <br /> NUMBER OF"NO UNITS: I NUS16E1 OIF pf1FdI00yMt:� NUNIREI OF FMPLOYHS: �/ <br /> CHARACTER OF SOIL TO A DEPTH OIF�33 FEET: 1AA AfT/SyUMP SOIL CNARACTE1t / WATER TABLE DEPTH 10r <br /> SEPTIC TAMOOREASE TRAP yBTYPE/MFG FRAZI GJ cAPACRY ,1000 No.COMPARTMENTS ry4 <br /> PRO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL _sd 1 FOUNDATION �C J FROFEATY ME�� <br /> UFT STATION❑ SIZE TYPE OF FNyIM/P SAND OIL SEPARATOR IENCLOSEO SYSTEM) <br /> LFACNNO UNE lw M.S LENGTH OF LINESaE_ — 910 DISTANCE TO NEAREST:WEX— FOUNDATION �C / PROPERTY UNE _ <br /> RLTEA BED ❑WIDTH IDIDTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH IFNOTH - DEPM DISTANCE TO NEAREST:WELL PROPERTY TY UNE <br /> SEDAOE HIS ❑DEPTH 8RE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SU " 11 WIDTH LENGTH DEPTH DNITANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL FONDS ❑WIDTH LERGER DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS ARROGATION ANO THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RI 8 O <br /> AND REGULATIONS OF THE SAN I0AOUI.COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORMA.' CONTRAROR'S HIRING M <br /> SUBCONTRACTING=NATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK MR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS Of CC(AAI-IMRRRNNNII�A.'/THE <br /> �APPHCANT MUST CALL 24 IOUII IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPLETE DRAWBIO BELOW. <br /> SIGNED% � N /[.B�-'lA!/F-4O TUM e" <br /> ' DATE: <br /> T RAN(DRAW TO SCALE)SCALE 'ro <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISMSA SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE NSMSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAMS. THE PROPERTY OR ADJOINING PROPERTY. <br /> — ag0 � <br /> PAYMEW <br /> A%:!rEjVED <br /> JUN 9 1995 <br /> PUBLIC HEALTH SERVICES <br /> NVIRONMENTAL HEALTH DIVISrOry <br />