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Ste. <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> 'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> BOX 388,445 N.SAN JOAOUIN ST.,STOCKTON•CA 95201.0388 <br /> (209)468.3420 <br /> �� .�Za'•`^_:.,1,� <br /> 1811-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OIITEIS8UE0 <br /> CONSTRUCT <br /> it DIOR NBT <br /> APPLICATION 18 HBt®\,MADE TO THE BAN JOAOWN COUNTY FORA PHiAMT TO CONHIRUCT ANO/DR INSTALLT1/E 4VOi7C DESCRIBED.THIS A14UCATR7N 19 MADE M COMPLIANCE WITH SAN <br /> JOAQUN COUNTY COVORDPMENT TITLE,CHAPTER 9.1110.3 AND THEE STAeN'D;A�RDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENIARONWNTAL HEALTH DIVISION. <br /> JOB ADDRE9WOR A �� , (I �r•„\h�,{per-+ T'�C��,1 CIIY�[ �1 ]I LOT SIZE <br /> 1 . <br /> F OV�NER•s N OMI I n6 P , iI T—lt U U� S8,,4i7,�1N�E L�^, •,�rf15 rl����Pf.(� <br /> CONTRACTOR �.ADORFAB � _` C? \G �' 11C scl2 r410N e-��aa <br /> RK1$CONTRAC70q <br /> � � ADDRESS - IJcf PHONE <br /> TYK OF 89NC WOML. MEW INBTAILATBN 13 REPMR/ADOITION MINUCTION❑ <br /> IND SEPTIC SYSTEM PEIVA TTED IF PUBLIC 18 AVAM,ABIE WREN 200 FEET OF BLI DING.( PYIC 7'B87W()NOW MANY <br /> •�18♦ AFBSNN$BSR f <br /> INSTALLATION WILL SERVE- RESIDENC COMMERCIAL OTHER❑ <br /> NUMBER OF LIVING UNITS: 8R OF BEDROOMS:JJ NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ PTTIP 500.CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANR/DIEAeE TRAP ❑TYPEIMit CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPEnTy LIE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM! <br /> LEACHING LINE ❑ ND.i LENGTH OF UNE1{ S2 gSTANCE TO NEAREST WELL FOtMDAT10N f71DPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIo-H LENGTH y OEFrH DISTANCE TO NEATEST:WELL aEj �_.F.ODU.N,�D,ATION PROPERTY LINE <br /> SEaADE arts �OEPTN ZE�=_ ,t'MIMDEEER DISTANCE TO NEAREST:WE '�^-•TKN� UNE <br /> SUMPS ❑MOTH LENGTHH �O - DEPTH V DISTANCE TO NEAREST:WELL VFOUN DAMN PROPERTY LINE O <br /> OMSPOSAL PONDS ❑WROTH LENGTH DEI'OI DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> — <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TI APPLICATION AND 7HAT THE WORK WILL BE DONE IN ACCORDANNCE WTH SAN JOAgUM COUNTY ORDINANCES AND STATE(AWS,AND IKMES � <br /> AFM REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFYTHAT N THE PERFORMANCE OF THE WORK FORWHICH . <br /> THI6 PERMIT IS RS <br /> ISSUED,I SHALL NOT EMPLOY ANY PEON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WORKMAN%COMPENSATION LAWS OF CAUFOF"k•CONTRACTOR'S HSYNO OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOV NG:•1 CERTIFY THAT N THE PERFORMANCE OF THE WOW.FOR WHICH THIS PENAIT 18 ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO (� <br /> WORKMAN'S COMPENSATION LAWS OF CAUFOHNIA," THE APPLICANT MUST CALL 34 HOW N ADVANCE POR ALL <br /> L RIEDUNI]®(N,SPE/CTS� no*s- COMPLETE DRAwwo BELOW. ( 1 <br /> SIGNED X TRLn:O • • 1L£ NTE: +�—,Qj—R—7 <br /> PLOT PLAN 4AW TO SCALE)SCAM. 'toAY wSt a"S� <br /> 1,NAMES OF STREETS OR ROM$NEAREST TO OR SOUNDING THE PROPERTY. ..LOCATION OF HOUSE SEWAGE DISPOSP <br /> Opr <br /> 2.OUTLINE Of THE PROPERTY,WITH UMFJFSION6 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL <br /> 3. dISENSIONEIE <br /> D OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES- E,ROGATION OF WELLS WITWN RADK/S ON <br /> INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR MJOIINM pNYWE1R1rRRY <br /> —� .,.......,,. �E,....... ........... ... . <br /> ............. <br /> I <br /> F' <br /> ...:......4......:......:...•..:......a.. <br /> ;.i ;...... <br /> . a. <br /> �,.. .....:....., <br /> ......4..... .... <br /> ,i <br /> .............. <br /> F <br /> .........`.... ... .............q....,a.....,...... . . . <br /> . .....:............ ....: o 2fl <br /> . . . <br /> S <br /> :. <br /> ..... .......,............. <br /> : .... .... :...... ......... ........ . ...... <br /> �. : <br /> -AA ...... <br /> t � <br /> E <br /> [ V <br /> • r <br /> , <br /> •fa <br /> 5 <br /> 'ASIBJLW OBMWROY YOJ.DIISOW ELL }�,. �-. ._._ __ •S7RNM INV'wav anwNn ,,.......•••w...�..��..._ <br /> CC 1�TZ 7,t N z AI�w 1 ;O <br /> DATE: <br /> APPLICATION ACCEPTED BY <br /> '�-+. <br /> TANK.PIT OR SUMP INSPECTION BY DATE' / I FINAL MI PECN�TION BY •`�^�t�'--=/�Z(Y'�'�ATE I�!E>.h / S <br /> ADDITIONAL COMMENTS:_ t"MA1 AA4ATIAw.A7C I p4T LXR/t.NA.�.�1"4 *.^ R�S:t A y /yup( N , <br /> ACCO VIITINO ONLY'. AIDE FAGS' <br /> PE CODE F-EEINFO AMOUNT RIPArTED HEC /CASH RECEIVED BY DATE SIR/FO ATT NtMM IFEVOICE f <br /> 5 DOD <br />