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APPLICATION FOR LIOUID WASTE PERMIT D U U ,l•7 SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES 7 F ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (ComplFts In TralkBb) APPLICATION 19 HEREBY MADE TO THE SAN JOAOUN COUNTY FOR A PERWST TO CONSTRUCT ARMOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WTTH BAN JOAOUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 9-111 .,3 AND (/•HE STANDARDS,OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRFOMR APN/_ [(y LO�/S' /�'E/'�Y'rIV 17(j'TC • CTA' �LO/T SIZE OWNER'S NAME �� /%,4,e- •s ADDRESS..F2-7�j1/ S�/N �_'^e P"Aj,n PHONE N CONTRACTOR��y (.9,QM IV}, ADDRESS • '-04L 2 - & OC��L) LIC/(v7� R10N'5-�5 8/ZS OUR CONTRACTOR�!/�)(r ADORES./ j, (,x'U'N'T/'/ TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRVADDITION DGTRUCTION❑ ANO SEPTIC SYSTEM PERMITTED IF PUBLIC HEWER IS AVAILABLE WITHIN 2DO FTET OF BUI IND.) P94C TFSTI.I I I NOW MANY ADMlwtbn/ INSTALLATION WILL SERVE: RESIDENCE%V COMMERCIAL❑ OTHER 11 NUMBER OF LIVING UMTS:_/NUMBER OP BFIJRDOMS:�_NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:(.//N P7T/RUMP BOIL CHARACTPO!�5 �OQ.µE WATER TABLE DEPTH /O SEPTIC TANKUOREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF RUMP'/_BAND OR SEPARATOR IENCLOSED SYSTEM) r LEACH MO URI NO.B IENOTH OF LINES � yO DISTANCE TO NEAREST:WELL!S I FOUNDATION�O PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑E VA LENGTH DEPrH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ( /� SEEPAGE RTS DEPTH S I SIZE 'k(O/, NUMBER DISTANCE TO NEAREST:WELL 100' FOUNDATION I dU P OPERTY LINE SUMPS T❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LME DISPOSAL POND$ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATIO AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RI)LES�^ ANDREBUUTIONSOFTHESANJOAOUIN COUNTY ER OR LICENSED AGENT'S NONATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT N THE PERFORMANCE OF THE WORK FOR WHICH v1, THIS PERM UED,1$HALL NOT EMPLOY ANY PERSO I SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR ` SUnCO CTIN SIGN URE CE IBES THE FOLLOWIN ERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I$HALL EMPLOY PERSONS SUBJECT TO�L I WORCM N'S COMP ATIO UW FORNI • T CANT MUST CALL 24 HOURS IN ADVANCE FO1IR AAy'�LL PROUMRFD INSPICTIONS. COMPLETE DRAWING/B,ELOW.q-•'� SIGNED% TIRE: ` eDATE: PLOT PUN(DRAW TO BC ALE)SCALE 'to , 1.NAMES OF STREETSL16201 S ST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPCSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WTIHIN RADIL/S OF ONE HUNDRED FIFTY FT.ON INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. . Q I. 76 1 . L F. l G/A�tlQ Ey s 'N A �>'r.Lea� ?�.' ?C► FOR DEPARTMENT USE ONLY AR'LICATION ACCEPTED BY DATE: _AREA: TANK,RT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY ATE 10. ADDITIONAL COMMENTS: ACCOUNTING ONLY: ADI FAC/ PE CODE FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE M/PIPMT NURHBEL wVOICE/ ,1/0 I l r / n I✓ /U 97 / 3 6 8