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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,904 EAST VJEBER AVENUE.STOCKTON,CA 95201388 <br /> (2091 4883420 <br /> N011-REFUNDA PERMS YEA FROM DATE ISSUED <br /> ICBIp"in Tdpnnt!} <br /> APPLICATION IB HERESY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND"INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMFIJANCE WITH BAN <br /> JOAQUIR COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 ANO THEDAR06 Of SAN,JOAOUIN COUNTY PUBLIC HEALTH SERVICE,ENVI/10 NTAL HEALTH DIVISQN. <br /> JOB ADORESS/OR AAVI / / CT' - _LOT SRF <br /> OWNER'S NAME /J ADORERS P40'NE <br /> COMPACTOR ------ttltl'rFF ADDRESS'64 a <br /> Ste CONTRACTOR ADDRESS LICE _PHONE <br /> TYPS OF SE111C WORK: NEW]INSTALLATION IV RH9ASVADOITION ❑ DNTRUCTION❑ <br /> 010 SEPT':SYSTEM PERMITTED IF P UCLIC WA'Fq IS AVAILABLE WITHIN 200 FEET Of SUILDINO.I POW TBSTW L 1 HOW MARY <br /> 4pk"-E <br /> INSTALLATION Will SOMI: RESIDENCE 1, COMMERCIAL ClOTHER 0 L <br /> NUMBER OF U~UMTS NtaoW Of IMFIOOMS. 4 ML-MM OF EMPLOYSLi: <br /> CHARACTER OF ML TO A DEPTH Of 0 FEET; PTT/BUMF SOIL CHARACTER: WATER TABLE DEPTH_ <br /> SE►TIC TANKfO11fASE TRAP ❑TYPEJMFO — 41 CAPACfTY% <br /> (� _NO.COMPARTMENTS <br /> PEO TREATMENT RANT❑ DMTANCE TO NEAREST. WELL a FOUNDATION PIOTEpTY UN! <br /> LIT STATION❑TySm TYPE OF OUM am`SANE OE.SEPARATOR IENCLOsED SYSTEMI �/L <br /> EACMNO[ 1al)NO.•LENGTH OF LINES b O I a <br /> —L yDISTANCE TO NEWEST:W$L ,wNDAT1ON�_PROPERTY L.E �D! <br /> BITER ❑WROTH LENGTH_DEPTH DISTANCE TO NEAREST:WELL JN <br /> _FOUNDATION PROPERTY tE c <br /> Q <br /> MOUNDED WIDTH LENGTH OFPTH DISTANCE TO NEAREST;WELL <br /> FOUNDATION�—PROPERTY LINE_ Q <br /> �L�- <br /> SSPAa!PTS, DF!•TH BI2E NUAPoER _dsTAN[f TD NFAgEs7:WELL& !, .6PUNDATK)N �PROPERTY UNf.�� <br /> ❑WIDTH LENGTH DEPTH <br /> DISPOSAL PONDS 13 WROTH LENGTH DISTANCE TO NEATEST:WELL FOUNDATION PROPERTY LRE <br /> DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LlE p <br /> I HEREBY CERTW THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WKL BE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY ORONANCES AND STATE LAWS,AND RVIEB <br /> AND REGULATIONS OF THE BAN JOAOUN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTMIFe THE FOLLOWING:'I CERTIFY THAT 1N TME PERPOTW+WCE OF THE WORK W p WHICH <br /> THIS PERMIT <br /> IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON N BUCH A MANNER AS TO BECOME SUBJECT TO WOIICAIAN'S COMPENSATION LAWS OF CAUfORIRA.• CONTRACTOR'S RISING Oq <br /> SUB{ONTRACTING SIGNATURE CERTIFIER THE FOLLONANS;'I CERTIFY THAT N T1E PERfORI.IANCE OF THE WO'K FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMNY.S�fC'O�MP�ENSA]T�IOr/N LAWS Of CALFORNIA.' THE APRLCANT MUST CAl1 21 HOURS N ADVANCE FORRJ}ALL <br /> ,REQUIRED INSPECTIOIIi. COMPUTE DRAWING BELOW- <br /> BIaNEO% T �/'I(! f j. of <br /> J TRLL,lirY // DATE: <br /> 1 PLOT PLAN IOMW TO SC/LLE)6CALE r_•le <br /> I. NAMES OF STREETS OR IIDADS NEAREST TO OR BOUNDNG TME pROL•ERry �. LOCATION Of HOUSE SEWAGE dSPOBAI SYSTEM OR PROPOSED <br /> 2.oIRUFIE OF THE PROPERTY.WITH DIMENSIONS AND NLI <br /> ORTH MECTON, EXPANSON OF SEWAGE DIBPOGAL SYSTEPA.. <br /> J. D4MCNSIDNED OUTLNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.tOAT'ION OF WELLS WTTHIL MONS OF OHE HUNDRED FIFTY FT.ON <br /> C <br /> INCLUDMO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINITIO PROPERTY. <br /> .. ..... .^JQ <br /> H <br /> Y4 <br /> : . : . . <br /> : V <br /> ^PJAG <br /> : EP.,;! <br /> ;._ . ..... N,�[;0KVEti:Til HRALT biViS: <br /> FOR DEPARTMENT USE ONLY <br /> ICQ <br /> APPLATION ACCEPTED BV �L�--P--�41 ^� DATE:, _1� 1,1j AREA. <br /> TAMC,PIT OR SUMP INBPE BV �{— <br /> DATE 7 ! FINAL INSPECTION BY <br /> GATE d l 7 ' 9G <br /> ADDTTN)NgL COMMENTS: <br /> ACCOUNTINQ ONLY: AIDE FAC# ` <br /> FE CODE FEE INFO AMOUNT RSEMTTW OftWo&jjaAgK RECEV®BY DAT! SR I P'MT IBLEIIRIEIL CEO I <br /> n i . t ID �3Sa <br />