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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a , P.O.BOX 388,446 N.SAN JOAQUIN ST.,STDCKTON,CA 95201.0388 (209)488-3420 } NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM IDATE ISSUED y ICampl&1a in Triplir&BTI APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PFRMIT TO CDNSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 3-1110.3 ANDSTANDARDSGOF SAN JOAQUIN COUNTY BLICCHEALTH ICES,ENVIRONMENTAL HEALTH DIVISION. �'r y JOB ADARESSIOR APNI 3 L. I �LJ�C I OWNER'S NAME I 1 i�G J� �Q n0 �� •'�Y 31—t p / 1 .�,. FT nI:1`S�L�1—MOPEDS F� p PHONE_ J Y"1 CONTRACTOR_ }1IL`P u1L>r ADDRESS �jVo AID)e (p�`p :. uC.F ZY6 "J PHONE SUB CONTRACTORADDRESS LIC& PHONE Tyre DF SEPNC WORK; NEW INSTALLATION RWAIIVADDITION❑ DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) FEiG TE87[r4[1 NOW MANY MWh.eon- 1^ INSTALLATION WILL SeWE: RESIDENCE El""COMMERCIAL❑ OTHER❑ }y NUMBER OF LIVING VNITS:--A--NUMBER OF BEDROOMS: NUMBER OF EMMOVEES: f CHARACTER OF SOILTO A DEPTH OFF 3y EEL: <1-J.PA�_PT=MP SOIL CHARACTER:_�Grt,;) WATER TABLE DEPTH SEPTIC TANKAWEASE TRAP 0TYFF/MFG p,�� _ pppAC(ry NO.Cp MPARTMENTB. �[ PKO TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE. LIFT STATION❑IST�IZE,�� " TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI 1 LEACHING LINE S� PIR'.S LENGTH OF UNE. l' DISTANCE TO NEAREST;WELL T FpUHOATM)N `PROPERTY UNE ? FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPEJCTY LINE MOUNDED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY LINE _ jam+ SEWAGE PCT& 1111"DEEPTH &TE NUMBER DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE R�M1 r S[ PB ua'w,pTH --LENGTH DEPFH__4-,LL DISTANCE TO NEAREST:WELL_LDj0± FOUNDATION PROPERTY LINE 7 _ 4+ DISPOSAL PONDS ❑mDTH LENGTH DEPTH DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PRWAREA THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JDAOUIN COUNTY.ROME O WNFRORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OF THE WOFK FOR WHIGH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOV ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING On ' SUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS of CALIFORNIA.'THE APPLICANT MEDT CALL 24 HOUII IN ADVANCE FOR ALL REQURm INSPECTION&,COMPLETE DRAWING SIGNED A TITLE: cn3n T'(-ge—+Of ....DATER r�/ l PLOT PLAN(DRAW TO SCALE].GALE_'In L 1.NAMES OF STREETS OR ROADS NEAREST TO OR BDUNDING THE PRDPERTy. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 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 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1 t L .......... ............ ........ ... ...... A ...... ........ Ci- D �I... .. sj ` T S °s k .... !. i�'Glb�- :.... :. ................... MAR'1 1996 ; ... : ... .C.. �$LICFTERLFL,SpG {II tryVLROPJMENTAI-HE ... ...:. . �i�clYhevtlL.... .I✓vY..... FOR DEPARTMENT USE ONLY rp[�+ APPLICATIONpCCEPTEO BV W AREA. �1 f�1�S1lMAJ<UAti DATE: — q TANK,PIT DREUMP fN5 CTION BY H^ _ DATE 3 1 Z 7 I 7,1f FINAL M.PECTION BY A. ADDITIONAL COMMENTS: T ACC BUNTING ONLY; AIDE FAC/ PE COBE F AMOUNT REMITTED EC /CASH IlwavIamily DATE M U PERMIT NIAHBER fNVO10E/ 4 FOPEOLALlo� �s I i .