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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.C.BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON.CA 95201"0388 <br /> (209)488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM MATE ISSUED <br /> U:ampIGBF u TT kmt.) <br /> APPLICATION 18 HEREBY MADE TO THE SAN IOAQUIN COUNTY FOR A PERMIT TO CONSTHUCT AND/OR INSTALL THE WOIK DESCRIBED.THIS APPLICATION IS MADE IN COMPLJ.VY_E WIT N BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITTLE.CHAPTER 9-1110.3 AAV THE RTANUAPDS OF Bµ EAVI <br /> JDADUIN COUNTY PUSUc HEALTH CEB ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADORE,,SJOR Q / <br /> cm <br /> OWN :.OT7SIZE / < <br /> ER'S NAM! ACORESS ' PHDNE���7``J IEJ�y <br /> CONTRACT O ADDRESS <br /> BUB CONTRACTOR ADORES <br /> 0f® VCA PHONE <br /> TYPE OF 440"n WORK: MEW INSTALLAnON Q TION DESTALICTION❑ <br /> NO SEYCIC SYSTEM PERMITTED IF SLEEK SEWER IS AVAILABLE WITHIN 2DO FEET OF BUILDNG.j <br /> PFRC TEBTbI[I IOW MANY <br /> I_ <br /> NSTALLAnON PALL fOIVE: RESIDEApple U.e <br /> NCE COMMERCIAL OTHER❑ <br /> NUMBER of HYIFIO UNITS: NLMSEI OF SLDRO e: ` NUMBYR w EMPLoYEEe: / �y <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: MP BOIi CHARACTER: WATER TABLE DEPTH <br /> GEPTC TANKAiIFAfS TRAP �T\'PE/Mw '214! CAPACITY �Q _ <br /> 1�1 NO.COMPARTL*NTB <br /> R <br /> PKO TREATMENT AM IJ D16TANCS 70 NF11RE4T: WEll10c,It wUNDATIONy �— <br /> LIFT STATION❑v812E TYPE OF PUU`IMP q BIWD OIL 6F➢ARATOF FOUNDATION <br /> SYB/EAO rmnmY UNE`s f <br /> LEACHING UNE YF.Pp."NGTH OF u ' o'er V p.1 ANCE TO NEARBET;WELJ�f0�TJON e 0' PpoftW Y ONE <br /> FILTER BED ///❑WIDTH LENGTH DEPTH DISTANCE TO NEMFSr:WELL –`i` <br /> MOUNDED ❑WIDTH wUNDATIOry PROPERTY LINE <br /> T��y �� NOiNpEPTH DISTANCE TO NEAREST:WELL.FOUNDATION PROPERTY INE <br /> 8®HOE PTB 11•L•1l DEPTH 512E_���NuMFIEFI pI97ANCE TO NEAREBr:WELL roV' FOUNDATION pRppEEIY UNS� '>~ <br /> GIMPS ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAAESTI WELL FOUNDATION <br /> DISPOSAL PONOGPRWHTn'LNE <br /> ❑WIDTH LENGTH.i_PERTH DISTANCE TO NEWEST:WELLFOUNDATION—� PROPERTY UNE <br /> I HEREBY CERTIFY THAT 4 HAVE PAEPAREO THIS APPUCAT10N AND THAT THE Wb RK WILL BE DONE IN ACCOMANCE VWM.'MIN JDAOUIN COLNFY ORONANCEB AND STATE LAWS,AND RULLB <br /> µD REGULATIONS OF THE SAH JDAOV IN COUNTY.HOME OWNER UR LICENSED AGENT'S B16NATUPE CERTIFIES THE FOLLOI/M o!•I CERTIFY THAT INTHE 14NFORMANCE OFTNE WOR(FOR WFSCN <br /> RHI$PEPNIT S IBBVED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAWS COMPENSATION LAW"OF CAUFORNA.• CONTRACTOR'S HWMG OR <br /> SUBt MAWSC oM SR SATION E CERTIFIES THE FOLLOWING;"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOS{WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS BUBJftT TO <br /> WORKMAN'S COM SATION uW5 CALIFORMA•THE APPUCAHT M\ T CALL 24 HO <br /> IN ADVANCE FOR ALL MQUI NEED INS TIONS. COMPLETE DRAWING BELOW (? <br /> SIGNED x - TITLE; Y 1 F <br /> DATE:��t/�`i`•� �� <br /> PLOT RAN(DRAW TO BCA!LI SCALE '—YV�-- <br /> I.NAMES OF STREETS DR ROADS NEAREST TO OR BOUNDING THE PROPERTY. e <br /> 1.OUTUNE OF THE PROPERTY,WITH DIMENSION AND NORTH DIRECTION. t.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED3.DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, WI <br /> EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> INCLUDING COVERED AREAE SUCH AS PATIOS.bIMVEYYAYe, <br /> e.LOCATION OF WELLS THIN RADIUe OF ONE HUNDRED FIFTY FT.ON <br /> µDW THE PROPERTYOR ADJOINING PROPERTY <br /> P <br /> . _ .. AYIV1�N7 <br /> AUG Z7t : <br /> oA.N J... . .. .� <br /> ALT ; y..., <br /> iGN VI c <br /> �AfVIR 80I, <br /> p b�V15I'ON <br /> .. <br /> S <br /> �HEAL <br /> .. .......... .�.. .. <br /> i < 1 <br /> FOR�IT <br /> DEPARTMENT USE ONLY `/(/� '•W J L E/APPLICATION ACCEPTED BY DATE:_ V �S � T•T' <br /> �'" ARL:TµK n1-SUMPINSWLCTICN fL�'`JFINµINSPECTION BY <br /> ADDITIONAL COMMET.'TS: <br /> ACCOUNTIND ONLY: AID/ FACT <br /> PE COPE FEE DIw AMOUNT REASTTED CHFD /CASH RECEIVED BY DATE SA,—IT N <br /> L <br />