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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 06201-0388 (209)4883420 NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUE WAv*kts Is TF¢NEau) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAOR INSTALL THE WORK DESCRSED.THIS APPUICATION 16 MADE N COMPlJ 410E WfTH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND/THE^STAFDAR DS OF SAN JOAQUIN COUNTY PUBLIC HEALTH,SSEERrV�I�CES,ENVIRONMENTAL HEALTH DIVISION. - e_ JOS ADOPESSIOR APNF_ 1� d 2 a �/ S V 0'1 G_ t 4g 41) CRY LI D'-OLO'� ___ �{L07 6�� OWNER'S NAME �L Nin �r�Y (00L Wl ADDRE88 PHONE, CONTRACTOR FAA I,K ADDRESS �[7 Ni 1C �y S71 L,Ca s a+ _P'n0NE a-, --�7�3 Sue CONTRACTOR ADDRESS .y UCS _PHONE TYM OF 467T1C WOWc: N,`.W INSTALLATION❑ RSPAAVADORION IQ D61T1UCTION❑ NO 8EPTIC SYSTEM FERMRTED IF PURU^.SEWER 18 AVAILABLE WITHIN 200 FEET Of 6UU N GJ P91C TTLSTM)(I IIOW 4URMY . �PSISINIR� INSTALLATION WILL SEINE: RESIDENCE 2COWMACLXL❑ OTTER❑ NUMROI OF LRRNO UNIT4: I NUMBER 4f 1116DROOMS: NLarIER OF 11101PLOY6S: CHARACTER OF SOK TO A DEPTH OF 3 FEET: S c,Af.R/ PITISUMP SOIL CHARACTER: WATER TABLE DEPT)( SEPTIC TANKMPEASE TRAP ❑TYPEIMfG_ CAPACITY NO.COMPAATMENTS N(O TNMR EATENT ANT❑ DUTANGE TO NEAREST: WELL FOUNDATION PRDPEP.TYUNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) ICEN[ E6�-110. LENLN LENGTH OF 1.11111 L-1,a EA4N0 LIDISTANCE TO NEAREST:WELL—plat FOt%OATIDN _PROPERTY UNE �V I HLRBR SED IJ WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:VAIL FOUNDATION PROPERTY LINE U MOUNDED ❑WIDTH LENGTH DEFT14DISTANNCETO NEAREST:WELL._FOUNDATION PROPERTY LINE 4EEPAE4 091811DEPTH SIZE _NOMBEII DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE L GU MP4 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL _FOUINUATION PROPERTY LIE C DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL__— FOUNDATKN PROPERTY LPN r' I HEREBY CUITIFY THAT I HAVE PREPARED TFN8 APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WT(li SNE JOAQUIN COUNTY ORDNANCE@ AND STATE LAWS.AND MOLES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'8 SIGNATURE CERTIFIES THE FIX10WIN0:'I CERTIFY THAT IN THE PERFORMANCE OF TIE WORK FOR WFSCH THIS PERMIT,S 1SGUED.I SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HSBNG OR SUB-CONTRACTING WNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 BHALL EMPLOY PERS ONB BUBJECT T1D WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALE 24 HOURS N ADVANCE FOR ALL REOLAR(ED INSP[CTLOIES. COMPLETE DRAWINTIT L r BIONEDX / / �( j�It� TRIf.: �l'1 V`rt•SG�D� DATE: V VVV ROT PUW MUkW TO SCALER SCALE 't0 I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LDCAYION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUT UNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DMECTION. EXPANWON Of SEWAGE DISPOSAL SYSTEMS. 3. INMEN%ON ED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WITHIN MDFM Of ONE FIFTY HUNDRED FT.ON INCLUDING COVERED AMA$SUCH A8 PATIOS.DRIVEWAYS.AND WALKS. TIE PROPERTY OR ADJOINING PR0PORY. . .. ....'....................... .. . .1rE ..i.. :.. .5... .,...... .... ENS......qFC ; .. . a .. F $ .. :rss �• :...SAN:'10.4 � ENViRO EAl.�li.� CN £ IrICtS. .. - . . ....._... ?��AEAL HiY/lr+S; - 40 amt S-� L.QL 101 :....: .. . ... -. ... . .l. IV) ............. . P /n- FOR O47ARTMENT UK ONLY 9 APPLICATION ACCEPTED BY �l DATE: \\— 7— A1EA:_y �y / TANK,PR OR SUMP INSPECTION BY DATE I I FINN INSPECTION RY )Ol ,A1,L�t_Q�I^ -:> DATI L! / / t�y W ADDITIONAL COMMEHTO: ACCVVFRONG ONLY: MIDI FACT ` W CODE FE INFO AMOUNT REMTTID F@K RK9VED{y DATE M I FYMBT NUMBER IFNOICE S 421 rtS f o.o b852-1