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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L,( <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> ND&REFUNDABLE PERMIT EXPIRES I YEAR FRDIA DATE ISSUED <br /> (CDNpIDts It Trips"ttl <br /> AMPCATON IS HEPEBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOTR INSTALL THE YORK DEDCRIND.THIS APPLICATION 19 MADE N COMFUAHCE NRH DAN <br /> JOAOUN COVNrY OEVRAPMENT T/ <br /> RLF.CHAPTER 8-11110..3 AND THE STANDARDS OF DAN JOAQUIN COUNTY PUNAC HEALTH <br /> y@EET�f M ENVIRONMENTAL HEALTH ADDRESS/011 ADORESS/OAPNI ;^JJ� <br /> `CA'y CITY C�`3G _ __ __ LOT D12F S X/`�O/ <br /> owHEn'HAnrt"4-- <br /> _q/LLQ.0 A/DMSe {�•N/� ,)S, (��( <br /> CONTRACTOR A <br /> /"`�•" ��, ADDRESS l� C `. ��'el LIC/ Y ``�22r <br /> SUR CONTRACTOR ADDRESS LIC! M40NE <br /> TYPE OF SEPRC WORK: NEW INSTALLATION❑ R'OASVADDITON DTITRUKTION❑ <br /> ONO SMC SYSTEM PERMITTED IF PUBUIC SEWER 16 AVAILABLE WITHIN ZOO FEET OF DUMX—J PHIS TE7T(el I 1 NOW MANY <br /> .y�y^ AfFietten/ <br /> NtiAWTION WALL DUM! R EMDENCE EJ COMMERCIAL ElOTHER(JNUI,sm OF LENS UNITS: <br /> RUMONR OF SEDIIOOMS. NUAV M OF VAPLOVME <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FSM: 5 "D MT/SUMP ML CHARACTER:'5*fn T) WATER TAKE OEPTH IDD' <br /> Smk TANK/OIEASE TRAP ❑TYPFWM CAPACITY NO.COMPARTMENTS <br /> ►KG TREATMENT PLANT❑DISTANCE TO RFARbT: WELLFOUNDATION PROPERTY UNE <br /> UFT STATEN❑N�SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACHING INE LQ'NO.a LENGtH OF LINES /-410/ DISTANCE TO NEAREST:WELL " b FOUNDATION l-, P OPERTY LAE �- <br /> FILTER DIED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LJNE <br /> MOUE/DED ❑"or" LENGTH DEPTH DISTNICE TO NEAREST:VIHL FOUN DATON PROPERTY UNE <br /> imAO R RTS ❑DEPTH ORE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY WE <br /> SUMPS �WIDTM r�-! LENGTH /0' DEPTH ICN I�OrSTAJCE TO NEAREST:WELLZO2I FOUNDATION Ib` PROMITTYUNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 1 HERESY CETTIPY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE N ACCORDANCE VRTH SAN JOAOUN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> ANO R EGULATIOND OF THE DAN AAOUIN COUNTY.NOME OWNER OR MENDED AGENT-D UWA <br /> SONATVIE CERTIFIED THE FODNG:T CERTIFYTNAT LATHE PtMOMW CE OF THE WORK FOR WIMCH <br /> THIS VEMM INISSUED,1=NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO DECDALE SUBJECT TO WOP MAN'S COMPFNSATON LAWS OF CAUPOPOUL' COMMCTOR-S MRNO OR <br /> SUB-CONTRACTING TURF CERTIFIES THE FOLLOWSFG:'I CERTIFY THAT IN THE RFOPAANCE OF THE WOR[FOR WHICH THIS PEMIIT ID IDMEO,I MIALL EMPLOY PERSONS OUSACT TO <br /> WO 'B COM DATION LAWS OF�CAJFOOOIIA.' TN RIC T ST CALL s="iR ALYVANC[FOR ALL RWU/I!D IMSPECTIOM. COMPLETE OOUAVANO BELOW. <br /> r Q <br /> DIO x <br /> \JL TfRE: � DATE: <br /> ROT PAN p1lAW O SCARI SCALE 'to <br /> 1.NAMED or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY- A.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR REPOSED <br /> Z.OUTLNAND NORTH OF THE PROPERTY.WITH DIMENSIONS ANORTH DIRECTION. EXPANDON Of SEWAGE DISPOSAL SYSTEMS. <br /> 3 M <br /> .D"ANONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED"UCTURES, S.LOCATION Of WELLS VATHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> MLUOM COVED MFRS SUCH AD PATIOS,DRIVEWAYS,AND WAXS. THE PROPERTY OR ADJOINING PROPERTY. <br /> .... <br /> .. i .. . - .. 7 ... <br /> .:. .. ... :. ..:.. I _+ <br /> .. .......I.. ... <br /> I, .... <br /> ........ ... - ..o....... .. .. .. <br /> .. ... ......._I - l 1/ <br /> wC(I <br /> : <br /> „1 <br /> A'Aatlh� .. PAYMENT <br /> ... ... f P R1d � <br /> POESL, <br /> FOR DEP ENT W E ONLY /7 <br /> APPLICATION BY R DATE: AREA 'L/� <br /> TANK,PIT SMTP SPECTM14 By DATE FINAL INSPECTION SY DATE ! / <br /> ADORIONAL COMMEND:f <br /> ACCOUNi1Ra ONLY: AID! fAC1 r p�y pL <br /> FE CODE TEEUNFO AMOURT RBAITED IC ASH /IEC Um by DATE DR/MRNST NUMBER RYYOCE! <br /> Pub.HeaRh Sen.-Emiro.174(31N) <br />