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APPUCATION FOR LIOUIO WASTE PERMIT <br /> !�AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> -� i ENVIRONMENTAL HEALTH DIVISION <br /> Q4 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> AGM REFUNDABLE PERMIT EXPIRES I YEAR FRGM DATE ISSUED <br /> ICampits iw TrbiEBb) <br /> APPLICATION IB HEREBY MAGE TO THE JOAQUIN COUNTY FDR A POMAIT TO CONSTRUCT AMAR INSTALL THE WDIEC DESCRIBED. THIS APPLICATION IB MACE DI COMPLIANCE WRH BAN <br /> JDAOUW COUFTTY DSVELOPM NT ITTLE.CHAPTER <br /> 9-1110.3 AND THE JOAQUINHSTANDARDS OF SAJOAdN COUNTY pun= M IKRHCE4 IG-RONBEHTAL HEALTH G`IBSGN. <br /> JOB AGOESWOR.APN■ I�to 1-(T 1 1 J G fto CTTY�1 l0T tpze�G <br /> OWMIER•B NAME 5 cA L,4 a ADOMS9 s <br /> CONTRACTOR_ .L,G• f;.A/Cr- —ADDRESSii LIFS:-0 <br /> LICF RIONE�3(!}71-) <br /> f <br /> DUB cof CTOR ADDRE69 �.1/y/L�"T`-�-•�� L� I rJ A. <br /> UCF R10NE <br /> TYPE OF SEPTIC WORK: NEW WSTALLATION RFPMWAOOITION❑ DESTRICTION❑ <br /> NO SEPTIC SYSTEM PEM7 ED 1F PUBLIC SEWER IS AVAILABLE WITHIN]OG FEET OF SUIL H0.I 1'ERC YES%11 1 1 NJW N oUly <br /> ASFSeFY-I_ <br /> WSTALLATTON WR1SErVE: 11ESNAWT V'COMMEACIAL❑ OTHER❑ <br /> NVRBDI OF WIMO I/FSTS:�_MlEr.3E1 OF■ED1100MS:�_NUMBER OF EMPLOYEES: <br /> CHARACTER OF ROK TO A DO"OFF!/FEET;•��<-"d. PTT/SLDAP BOR CHARACTER: WATER TABLE DEPTH ^ <br /> SEPTIC TANJUGF&ASE TRTYPEIMT-U �J fnL CAPACFTY I��SA NO.COWARIENTS CM- <br /> PKG TREATMENT RANT d DISTANCE TO N[iMFJT: WELL fOUNOATpNPROPERTY LINE--ICL �_ <br /> VT STATIOR❑�A LENGTH OF IJNEB F PUMP SANG OIL SEPARATOR ENCLOSED SYSTEMA <br /> LIF ACHIHa UNE OIC DWANCE TO NEAREST:WELL-In h POUNOATNMI-i!a-PROPERTY UNE1� <br /> RLT9t 9ED ❑WIDTH LENOTH_ DEPTH DISTANCE TO NEAREST:WEI.I FOUNDATION PROPERTY LINE <br /> MOUNDED 13 WIDTH IiNOTN_ DEPTH DISTANCE TO NEAREST:WELL FCUNDATIDN PROPERTY LINE <br /> SEWAGE RTI ❑DEPTH BRE _NUMBER (NOT ANCE TO NEAREST:WELL YOU NDATION PFIOKE UNE <br /> SWM R-WOTH LINGTH_11NES DEPTH1t_DISTANCE TO NEAREST:NIELL1fI6,__FDUNOATION_�_PROPW Y LINE-� <br /> DISPOSAL PONDS ❑VVEJTII LDIiTH­OSPTH PFTANCE TO WARECT:WELL__FOUNDATION PIOPERNY UNE <br /> I HEREBY CERTIFY THAT 1 HAYS PREPARED THIS APPLICATION AND INAT THE WORK Will BE DONE IN ACCORDANCE WITH SAN JGAOUW COUINTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGLRAiIONS OF THE SAN JOAORRN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERrFOES THE FOLLW*WG:7 CERTFFYTHAT N THE PETIFOPAANCE OF THE WORK FOR VA41CH <br /> TWO PERMIT RB ISSUED,R SHALL NOT EMPLOY AMY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WOWJAMn COMPENSATION LAWS OF CALIFORHIA.- NHTRACTOP-8 NIRNNG OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOVYONO:M CERTIFY THAT IN THE PERFORMANCE OF THE WOIRC FO•A WWH THIS PERMIT IB ISOM.1 SHALL OAFLOY PERSONS SUBJECT TO <br /> WORLMMYO CONFPENSATIION LAWS OF CALIFORNIA,- THE AIRLNCANT MUS'CALL 24 HOW IN ADVANCE FOR ALL RSOLIRED INI/FEGT DNB.COMPLETE DRAWING OELOW.p <br /> BROHED X �!(L/ Tffll:� G-n N tY'G[1Te f GATE: 1 <br /> IT Fr <br /> PLOT PLAN(DRAW TO SCALE:SCALE 'Ie <br /> 1.NAMES OF STREETS 014 ROADS NEAREST TO OR SOUNDING THE PROPERTY. S.LOCATIDN OF HOUSE SEWAGE DISPOSAL SYSTEM OR P OPDBD <br /> J. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DRP)OJLL SYSTEMS. <br /> 1,DS.IENOIOFED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCIft"S• S.LOCATION OF WELLS WITHIN RADIO OF ONE"UNDO®FIFTY FT.ON <br /> INCLUDING COVERED APEAS SUCH AS PATIOI•DRIVEWAYS,AND WAlKB. .THE POPETO'Y•OR AD"NING PROPERTY. <br /> ... ... O. <br /> �............ <br /> file <br /> <.. .......... .. ......:.............:..... .....'.......:.....1.......:..:.. LIGHf'A17F.I.$EFe111Gk5 ..... .. . <br /> S <br /> ... ,J .....:.....•E......:.. <br /> ENVIRON 4ENTni.iiEHLTrI LxVI L:I4 <br /> : .. <br /> r... <br /> ... <br /> ;... <br /> r: <br /> 'T <br /> Q <br /> ' L <br /> .....:-...:._....... ... .. .j .. ............... ...... .... .. <br /> ............ <br /> t <br /> v <br /> N <br /> ............' ...'...:... .. ...` . S.. <br /> A. ....... :...:...... ... .... ... ................:. ..........:.... _...... <br /> . <br /> AJ✓ �� l F OEPMTMFNT IME ONLY `Y : <br /> APRICATION ACCEPTED BT " DATEo EA <br /> : V (l(J pp <br /> TANK,PN OR BUMP.TI01N 6Y DATELC_J .CfL FINAL INSPECTION ATL'� � <br /> I/ !`a6 <br /> AOOITIONAL COMEMWfS: <br /> ACCOUNTWO OILY: NIDI FRCP <br /> PS COVE F91INFO AMM UmaT RBA I TEO CHECK/ BN RECEIVED By DATE a I PIPMT NUROM INVOICES <br /> Lb a q <br /> i200 <br /> Pub.HeaOh Se",-Erlvlrc.174(3196) <br />