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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTK DIVISKIN <br /> P.O.BOX 390,446 N.SAN JOAQUIN ST.,STOCKTON,CA 36201-0380 <br /> (2091468-3420 <br /> 11011tNEFUNDA81f PEAW EXPIRES I YEAR FROM DA71ISSUED �3 ���� (T}71 <br /> 1CMBpIMtB k fr*iw to) <br /> APPLICATIONS HERE%Y EIDE TO THE SAN JOADUN COUNTY FOR A PERMIT TO CONSTPUCT ANDIOR INSTALL THE WOR(DESCWDED.THIS,APPLICATION IS MADE N COMPLIANCE WITH SAN <br /> JOAOUN COUNTY DEVELOPMENT TITRE.CHAPTER 9-11110.9 AND THE STANDARDS OF SAN JOAEGUIRI COUNTY PATHIC HEALTH SERVICES,EVWONAENTAL HEALTH DINMON.�' <br /> JOB AODRRESSNP AFKA G CRY AC_ll Lor 00E <br /> OWNER'S NAME_- 717(3-Z 5AND1211J&1 NAM CT PNDNE_. <br /> CONTRACTOR Do tj em F-,5 At AOORIE9S P 0.1BOX 319 /N IZLZYJC UCF PHONE <br /> NM CONTRACTOR ADDRESS S j Y LIC/ PHONE <br /> TYPB OF SPDC WORK; NEW INSTALLATION❑ RPAwN4D01RON❑ D4ITNIcm"❑ <br /> MD SEPTIC SYSTEM PERMITTED)'PUBLIC BEYIEH R AVAILABLE VAT HN TOO FEET OF BUILDING.I RRC 70rTwi I I wl W MANY <br /> APw>+4A A_4 — - <br /> HISTALLATIOM WILL{STYE: RESWEIICE❑ COMMERCIAL❑ OTHER❑ <br /> NMN OF LTVWO AWT[: NUMBER OF BEDROOMS: RTAMML OF MPIDYEEA: <br /> CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PRISUNIP SOIL CHARACTER: WATER TABLE DEFI-H <br /> SEPTIC TAMIfI011EABE TRAP ❑TYPfAMFG CAPACITY NO.COMPARTMENTS, <br /> PKO TREATMENT RANT❑ OIS,TANCE TO NEAREST: WELLFOUNDATION PROPERTY RINE <br /> UFT STATION I] w-E ME OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTFMI <br /> LSACNNO LINE ❑ NO.A LENGTH OF UVEB_ DISTANCE TO N:AREST:WETL FOUNDARON PROPERLY UNE <br /> FILTER BED ❑WIDTH LENGThDEPTH DISTANCE TO NEAREST:WELL FOUNOMWN PROPERTY LINE <br /> MOUNDED 11 WIDTH LENGTH_ DEPTH OISrAWE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> {SAGE RTS 13 DEPTH SITE--NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPVRTY UNE <br /> AUMTO 11WIDTH LENGTH^^—OEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE <br /> DIBFOSAL FONDS ❑WIDTH LENGTH _OEFTN DISTANCE TONLAREST:WELL FOUNDATION PPOKATY UNE <br /> I HERESY CERTIFY THAT 1 HAVE PREPAMOI TMS,APFUCATMN AND TMAT THE WOR(WILL BE DONE IN ACCORDANCE wrrH SAN JOAQUIN COUNTYOROINANCES AND STATE LAWS,ANO RULES <br /> AND F46WLATMNO OF THE SAN JOAOUIM COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTTRES THE POILOVMq:'TCEKrIFY THATIN NC <br /> THE PVVLORALAE OF THE WORK POR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOFEWAN S CONPEISATION LAWS OF CMIFONNA.' CONTRACTOR'S HHMNG OR <br /> BUB�CONTRACTNG SIGIiAYt CERTIFE4 THE FOUyWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WINCH THI8 RERIAT IS ISSUED,1 SHALL EMPLOY PERBI SUBJECT TO <br /> WORLMAN'B COMPENSAT WB OF CAL( Iti N[AFHICART MII¢.T GALL U NOLIRS M ADVANCE FOIA AEL.1,REOIAR®UNRKRONS. COARPIETE D1IAWNG BELOW. <br /> SIGNED /U27` 7RLE:—/l M`�N DATE: L O <br /> PLOT RAN IDRAw SCALA%9CALF __to <br /> I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE—,—. 4.LOCATION OF HOUSE SEWAGE DISP'OSAI SYSTEM GA PROPOSED <br /> 7.OUTLINE OF THE PAOPERTY,WITH OMMIY IONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 081POSAL SYSTEMS, <br /> 3.DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED STRUCTURES, S.LRARE <br /> LOCATION OF WELLS WITHIN RADIUS OF OHUNDRED FIFTY FT,ON <br /> INCLUDING COVERED AREAS SIKH AS,PATIOS,DRVIEWAYS,AND WALKS. 'HE PROPERTY OR ADJOINING PROPERTY. <br /> R <br /> �x i ST�NC� <br /> O FF1 cE <br /> Q D1+oN� c � ERC- <br /> G�OCI�TfONAL � <br /> Z <br /> FDA D"AA-RIIT/MBIT USE ONLY 7 <br /> APHKATWN ACCEPTED B, L V`-' - `-'� DATE: `� D <br /> TANK,rrT OR SUMP SJS!'EC TTO BY AT FINAL W SIECTgN S,Y TE Iz 1 V <br /> ADORIONAL CO"MF"ITS: <br /> A4YOUNT!IG ONLY: AID( FACT <br /> TE COOS <br /> FEE NFO AMOUNT RDLIITTED CHSOSA MH KCMVED BY DATE N I FART NRSiN INVOCE F <br />