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APPLICATION FOR LIDUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION n V J q5D <br /> 304 EAST WESER AVENUE,STOCKTON,CA 95202 ( 't <br /> (209)468-3420 <br /> XQX REFURDAIIE PERMR EXPIREI I YEAR FROM DATE ISSUED <br /> + ICe1tPMb b TEIFlka T <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMR TO CONSTRUCT AND/OR INSTALL THE WORK DEBCWBEO. THIH APPLICATION it MAGE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY LI EYELOPMENT TITLE.C R 9.1110.3 AND THE ANDARUt SAN JOAQUIN COUNTY PUBLIC H�ALTH�§E j C�O+VIRD/ISIFJ+IAL HEALTH OMBION. <br /> JOB ADLNIEBS/OR APNI <br /> Q Lor et> <br /> OWNER'S NAM I ADORE99 RHONE •y` <br /> CONTRACTO fE 6 Q �a•I.J7'D �PVL7_i_i.l 7G4"7>= lK1 �I}�E� PHONE ?! <br /> i Cs G. ADDRESS /�— '-' 1e1��� <br /> SUSCONTRACTO^ ��2�y�✓ �� �'+C.. ADORESBI�� l• �Il�LJ4y�ib�� 11Cf J/r�rj�,i(P110NEL <br /> TYPE OF SEPTIC WORT: NEW INSTALLATIO REPAIRAAOOTTION Cl DESTRUCTION❑ <br /> M SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER M AVAILABLE WITHIN WITHIN 200 FEET OF BUILDING.) P6UC—TW 1 I NOW MANY <br /> 1 /1pF[sSen f <br /> WSTAWTION,IIILLf[INF: flES10ENCE0 COMMERCIAL❑ OTHFIT�I �,•'-•,/1 - <br /> NUM*EROFthANaUBTS: NUNS OFt BIW:.- - -____NB OF BMPLOYQS:y <br /> C R OF SOIL TO A DEPTH OF 3 FEET: PTTISUMP BOIL C/1AIV,CTI2R. WATER TA81E DEPT 14 <br /> svnC EASE TRAP ❑TYPE ATFO �f-' CAPACITY 1E?C/ �.coMPARTMEMe -- <br /> ��� <br /> PKG TREATMENT PANT❑ INSTANCE TO NEAREST: UL FOUNDATION ' ��rY��— <br /> (00 <br /> L1FT STATNNT❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR IENCLOSEO SYSTEMI <br /> LEACHING LINE �,NO.A LENGTH OF TNEB A DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY EINE <br /> FILM Sm Q WIDTH LENOIH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> MOUNDED Q LMDTH �I Wmt"-Tr_DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> S�AOE MTS -mH 'A>L SIZES-_�NUMBER DISTANCE TO NEAREST:WEU J 1' FOUNDATIONS PROPERTY—II <br /> SISMry ❑4Y1DTM LENGTH D1D'TH DISTANCE TO NEAREST:WEU <br /> FOUNDATION PROPERTY UNE <br /> DIt►OSAL POWs ❑WIDTH 'LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY,LNIE <br /> I HERESY CERTIFY THAT 1"AVE PREPARED THY ATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORMANCEB AND STATE LAWS,AND WOES <br /> ULATIONS OFT JOAOl/NC .H*ME OWNER OR LICENSED ADENT'S SIONATUFIE COMPIES THEPOJJA)~:'ICERTIFy THATdT1E PERF01M1ANCE OF THE WORIC PORWIBCH <br /> ■ ,1 T EMPLOY PERSON M BUCN A MANNER At 1D BECOME SUBJECT TO WOIKMAN't COMPENSATION LAWS OF C/1110RMA.' CONTRACTO"HIRWO OR <br /> M/BLONT IQ IFIES THE WING:•I CERF THAT M THE PEIrORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL E�iLOY PERSONS SUBJECT TO <br /> WOIKLAAH' 8A U C <br /> AN <br /> STC M/1DURf W ADVANCE FOR ALL BEDA-.', <br /> UI�N�®-7IMtPBCTIOIH.COMPETE pf1AVAHG SflDW. <br /> D X S�7 ",LL: " - DATE: Z <br /> ROT PUN mRAW TO SCALER BCALE -le <br /> 1.NAMES OF STREETS RO 8 NEAREST TO OR BOUNDING THE PROPERTY- <br /> I. �.LOCATION OF HOUSE BEWARE DISPOSAL SYSTEM 011 PROPOSED <br /> 2.OIRE OF T11E PROP[ .WITH IXMFNBIONB AND HORTH DIRECTION. EIUPANBION OF SEWAGE DISPOSAL SYSRlA6. <br /> J.DIMENSIONED OUTLIES ANO LOCATION OF ALL EX19TPMI AND PROPOSED STRUCTURES. [ LOCATION OF WELLS WTTIUN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVETED AREAS SUCH AS PAY".DRIVEWAYS.AND WALKS. <br /> THE PROPERTY OR AD.tOSNdO PIOFERTY. <br /> . a <br /> ir <br /> �. <br /> v._ _ <br /> ... <br /> a <br /> 0Alt <br /> s� 9 <br /> 000 c ( 7tAA/IL <br /> W qpy..... HEALTH DI�Vi8iPt+ ` <br /> tan ISS_.. � die <br /> .. <br /> _.._ <br /> w�- <br /> _. . .. FTS <br /> LcM b1 L?Aae5 a �fs <br /> FDR DEPARTMENT IME ONLY <br /> AREA., <br /> IO <br /> APPLICATN ACCEPTED BY DATE! _0;71- <br /> �L <br /> 1 /fG'Uz <br /> TANK,Pf OR BLIMP INSPECTION BY DATE FINAL INSPECTION BY ATE <br /> ADDITIONAL COMMENTS' <br /> / <br /> ACCOUNTETO ONLY: AID# FACE t <br /> 1K COD[ FEL INFO AMOUNTRBAIITEDNt�ASH RECbVED BY GATE M f PERMIT NLM 91 W V010E E <br /> ! ?5 soar <br /> 31 ijW ��� Yfil-P1 G� T.j �Y PJ•u'IA,�x Ta uF•-S.Q'Y�o ,�.•I cs- Is'w e . 4h-��oi�� <br /> Pub-HeBHn Serv.•EIIYIrO.174(3/86) •z/ y��c CvricREc•TIq� F'e r,-�AaKS Tn ®�J3fl X�GoaTb4cTg� [v r[y� <br /> s�c?+ V 1-r 4,J,k25, -P TIO a Fr s �7a r o ry� GJfi (3•^Anrl E r <br />