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APPLICATION FOR LIOUIO WASTE PERMIT <br /> SlM JOAQUIN COUNTY PUBLIC HEALTH SL-AVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 10 HEREBY MADE TO THE BAN J MkSol COUNTY FOR A PERMIT TO CONSTRUCT MOMS INSTALL THE MW DEBCR IED. THIS APRMATGN IB MADE IN COMPLIANCE WITH BAN <br /> J MtIm COUNTY DEVELOPMENT TTFF�TLE CHAPTER It-1110.3 AND THE ST T"OF BAN Aq'u�I,N�CO,UfNry RIBUC HEALTH ERME�ByENVN1D11 E/MK HEALTH DAMN. /r <br /> JOB ADDEBBAR APNI. 1 1V A�1 �V �• V�K-/�/C� `r�'/LJT/�L CITYG, LOT 812EL.L/4C/lA <br /> OWNEA'B ,AAIET/��V�N _M4 64-4n ADDRESS -I/FTrY��- /!�� ��J RIONE' C,/yy/-I �/� <br /> CONTRACTOR %_A 61L'`0-y �c G ADD1�88 ( l S-• •�/ T'K� IlC/ CSA-I ggHE (6�Y0 <br /> SUR CONTRACTOR MCNESS IMI RHONE <br /> TYPE OF AERIC WORK: NM INSTALLATION IEPNmADDTWN DESTRUCTION ❑ <br /> IND SEAM SYSTEM PERMITTED IF PUBLIC SEWER IS AV YATHN 200 FEET M BINURNO.I FUM TEST"I 1 1 NOW MANY <br /> APNIeeMn I <br /> INSTALLATION WILL SFRVE. RESIDENCE <br /> RESIDENCE ; COMMERIAL NOTHER 11NWREA OFDTIS ( OBEDROOMS: 3 NUKISEW M OYEFI: <br /> OFSOILOER FGFEETLC . NUWATER TARE DERV- <br /> RCT MEASE TMP 11 M_C,,6 CMAx: I(econ <br /> � <br /> NO.COMPARTMENTS O1 <br /> MO TREATMENT MART❑ INSTANCE TO NEAREST: WELL r 'f FOUNDATION (O / PROPERTY UNE <br /> LOFT STATION❑ SIZE TYPE OF RAMP BAND OR.SEPARATOR(ENCLOSED BYUEM) <br /> LEACHNO UNE >41 NO.B LENOTH OF ONES -9-IOo IZ Ot.0z-D STANCE TO NEAREST:WELL�TFOUIMATION �-S ' MC)K Y UNE <br /> FILTER BED ❑WIDTH LENGTH DERH DHTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIVE <br /> MOLNDED ❑WIDTH LENGTH DEPFH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE FITS ❑DEPTH WE NURIBER 08TANCE TO NEAREST:WELL FOUNDATMH PROPERTY UNE <br /> am" ❑WGTH LENGTH DEPTIH DITAME TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL FONDS ❑WIOTH LENGTH DER" DSTANCE TO NEAREST:WELL FOUNDATMN PROPERTY UNE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT E WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAWIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> ANDREOULATMNSOFTHESANJOAWGCO EOWNERORME ED MENT'a SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT N THE RPFOHAAlCE OF THEWORK FORW'111CH <br /> THIS PERMIT 1 D,I MAIL HOT EM O ANY N N SUCH A NER AS TO BECOME SUBJECT TO WOFKMAN'B COMPENSATMN UNH OF CAUMANIA.- CONTRACTOR-6 HIRING OR <br /> SVICONTRAETINO 81 IAT RTIFIES IE FOLLOW( 0:•1 CERTIFY H T IN THE FERFORMANCE OF THE WORK FOO WHICH THIS PERMIT 18 I88VED,I SHALL EMMOY FERS INS 8%RMCT TO <br /> M ,WMAR'S COMMNS T FORMA.' TPIICA•R 24 HOURS IN ADVANCE FOR ALL PFO INaPECTMN6. COMFIETE ORAMW BELOW. <br /> SIME0 X TITLE:�� y <br /> DATE: q. 3. <br /> MOT MAN DRAW TO SCALE)SCALE_ •,o <br /> 1. NAMES OF STATUS OR ROADS HEA TQ.OR ROUNDING THE M10FERTY. 4. LOCATION OF HOUSE SEWAGE DSMSA SYSTEM OR MOMSED <br /> 2. OVTUNE OF THE MMPERTY,WITH MMENSMNS AND NORTH DIRECTION. EXPANBMN OF BEWME DISPOBA WSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF W WITHIN AADUB OF ONE HUNDRED FIFTY R.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DPBVEWAYS,AND WAXS. THE PROPERTY OR APIDNINO PROPERTY. <br /> r � <br /> V r` <br /> 1 <br /> .. . <br />