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000isy <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1L ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 306,436 N.SAN JOAQUIN ST.,STOCKTON.CA 96201 0311 <br /> 12091 4813420 <br /> MON REFUIIQARLE PERMIT EXPIRES 1 YEA71FROM DATE HUED <br /> Ka"wn IS 711pu-14 <br /> APPLICATION IS"VIM MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CON6TRUCT AHD,OA INSTALL THE WORK OWMEO.THIS APPUCATgN Il MADE W COMPUANCE'MTTH EAN <br /> JOAQUIN COUV Y DEVF 0PMEM TITLE,CHAPTER 0-1110.3 AND THE 6TANDAPOS OF SAN JOA DUN COUNTY PUSUC HEJLLTH OWES.ENVIRONMENTAL HIMT/I WASION. <br /> // 7 ) t <br /> JOB ADDREewH AVNs .7�J ��-C((`�, T? e.-t At�'t f&,( C,>-�YJi a�f� LD;sini�� <br /> owNEA'S NAME E'�dCL'-ErLY- C YCCLJ`_t''_ —ADDRESS e,:, PHONE /A;/1�[/ <br /> SUBCONTRACTOR _ ADOfESS UCF PIDNE <br /> Typo OF acne WOIEE: NEIN IRSrAUAD0II❑ REPAMAODITION b"TNUCT"m❑ <br /> IND SEYFIC SYSTFM PERMITTED L'PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of l ,tilNa.I PVC TUTPI I 1 NCM MARY <br /> AP�oAAPn 5-.- <br /> INSTALLATION WALL SUNT. Af6OEACE CUMMfJICIAL❑ OTHER C] <br /> NRNBYI W UANG U NITS: TILA`MVI Of B NI~Of RIPLOYM' <br /> J <br /> CHARACTER Of FOIL TO A GERM OF G FEET:� RtP6lNAP SOK Cf1A1NCTER: WATER TAMI DEPTH <br /> SEPTIC TALKAREASF MAP ❑TYPEILIFG CAPACITY W.COWARTIVBlTA -,J <br /> MO TREATMENT PLANT❑ DIATAACE TO NEFLWAT. WELL FOU N..TIDN TEIOPERTY LAE G <br /> UFT STATION❑ SITU TYP2.OF PIMP SAND OS SEPARATOR IENCLOSED SYSTEM _ <br /> LEACHING UNE O HO.S LEHGT,OF LMS_ DISTELLANCE TO NEAREST:WFOUMDA(IONPROPERTY UNE T P <br /> PLTp1 SED )a qT1_L!_LENGTH- DEPT4 <br /> 1.CO DIBTANC[TO NEAREST:VYELL FOINKJATION 2 O Y PgPVIfY EINE _S <br /> MOUNOW PCI W1DTN IENGTH_ bMH DISTANCE TO NEAREST;WELLFOCNDATION PROPERTY UNE <br /> SESPAOE RTS Q DEPPH OU1 __NUSSSER DISTANCE TO NCALST;WELL FJUNOATION PROPERTY LAE <br /> NSAPS C3~" UENOTH___DEPTH DISTANCE TO NEAREST;W L__ _FOUNDATION PROPERTY UNF <br /> DISPGBAL P <br /> oNDA ClC]mm" LENGTH DEV DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I POESY CERTVY THAT I HAVE PF47AMO THE APPLICATION ONO TEAT THE WOW WILL BE DONE M ACCORDANCE WIT-SAN JOAQUIN COUNTY ORDINATCES ANO STATE LAWS.AND AVUB <br /> AND REGULATIONS Of THE SAN JOAOUEI COUNTY.HOME OWN"LICENSED AGENT'S BIONATLH<CEFITIRR.S TNEPOELON.'01G-.1 CERTIFY THAT IN7/Y FFIFOPMAEICE OFTIIEYARLFORWHICII <br /> THIS PE 196UED,I SHALL Y AIA'P'[11SON N C M.NNER AS To WCOAE SUBJECT TO WCFAMAN'S COMPENSATION LAWS Of CALIMPAK.'CONTRACTOR'S MEAS OR <br /> subt SIGFIATU IEC FOLIO WiNU..Cr TH.T IN THF PERFORMANCE OF THE V O FOP WHICH TINS PENWT HI ISSUED.I SNALL EMPLOY PERSONS ABJECT TO <br /> wO hl`fMAN'S CO H Of C RHI . 'I CALL b HOURS IN <br /> ADVANCE FO(F LLS.NEOLON D�fRf(NJ"%C'DONS-CDMPLETE DRAWING BBE1DW. <br /> PLOT PLAN IMAW TO LAU:1 SCALE__' <br /> 1.NAMES OF STREET OR RDADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PVOP I ED <br /> 2.OURUFE NNI <br /> Of THE PORFRY,WATH biMENONB DI WORT-DIRECTION. LXPANNOH OF IEWAGE DISPOSAL SSTS. <br /> YEM <br /> 3 UIM NOIDNED OVYLINES AND LOCATION OF ALL EXISTING AND RROPOSED STRUCTUIVF. S.LOCATION Of VAELLS WITHIN RADIUS Of ONE HUNDRED FIFTY FT-ON <br /> INCUUONO COVERED AREAS BUCN AS PATIOS,DNVFWA",AND WAILS TMf PIIDPERTY OR ADJOINING PROPERTY. <br /> tv <br /> -ffC.�KitlfiPt E:/r�ti5�% ICiLGIi. 1Z)w�.LP. .. . . <br /> f-ce7r�, .vtw A_J -�r•x 5'rR,�it21 1 1 1! .I .. ., <br /> I <br /> �ii�t1 Z 1936 <br /> FORCOAATMENT WEONLY DIF�o U <br /> AR.ICATON AGGERES eYf .�`�/W� )l'2' DATE: <br /> TAX.PT OR SUMP N4ECTCTN BY 1 L1,.��� DATE I I FINAL INSPECTION SY DATE /' • !•" <br /> ADDITIONAL COMMENTS: rl 1'ftlR V{G� / Ch.O� ' , LJ i' F 'T�{I ✓ <br /> ACCOUNTNO ONLY: NDA FACE <br /> RE CO:1S FH VIPO AMOUNT R6MTTE) IAIEC ,CASH IIECeVED ST DATE -1—T P—KNM INVOICE P <br /> ca 7, � <br /> 421 S 1 <br />