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APPLICATION FOR LIDIJID WASTE PERMIT SAN'JDAOUIN COUNTY PUBLIC HEALJI.SERVICES ENVIRONMENTAL HEALTH alt P.O.BOX 388,304 EAST WEBER AVENUE.StUCKTOR CA 95201.988 i f209I 468.3420 NON-REFUNDABLE PEMMIT EXPIRES ITA ROM DATE ISSUED �''' [CPInpMu GI TripUab) ! APPLICATION IS HEREBY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN _ JOADUIN COUNTY DEVELOPMENT TITLLEE,CHAPTER 9.11 1100y.3 AND THE STANDARDS OF SAN JOA IN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. t _ _ J, - JOB ADDRESCIOR APNF 7 ' L, X 2e, CIl'1' fL( C7„ '_LOT BIZE�� Lt OWNER'S NAME yy .ADDRESS PHONE CONTRACTOR }'� fr- ADDREse11✓. C- C�LL�/t.0 %� SSS rF �/1G FHONE_`� L .. SUB CONTRACTOR ADDRESS LICA PHONE L TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAI/DAODITOON DESTRUCTION 0 4 IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILdNQ.I FERC TFST(A i 1 NOW MANY iE{iE{ �j�(J�f APPA-d- INSTALLATION WILL SERVE: RESILIENCE LJ COMMERCIAL 0 OTHER❑ { NUMBER OF LIVING UMTS: 1 NUMaF I tF EORDOMS; 3 NI1MaSR OF EMPLOYEES! CH OF SOIL TOA DEPTH OF 9 FFET: PITISUMP SOIL CHARACTER: WATER TABLE OEPN1 EP71C TA EAaE TRAP ©TYPEIMTA CAPACITY NO,COMPARTMENTS �- .. REATMENT PLANT 11 DISTANCE TO NEARtz?: WELL FOUNDATION PROPERTY LINE II - LIFT STATION❑ BRE TYPE OF PUMP SAND OR SEPARATOR(ENCLOSED SYSTEM) r IElCHNO LINE ND.•LENGTH OF LINEA !_. —DISTANCE To NEAREST; O;r FOUNDATIONf 0 I PROPERTY UNE ffff FILTER DEC 13 WIDTH LENGTH DEPTH DISTANCE TO NFAAE6T:WELL FOUNDATION PROPERTY LME MOUNDED 13 WIDTH ry LENGTH DEPI71 DISTANCE TO NEAREST;WELL FOUNDATWN PROPERTY LINE SEEPAGE PL7a XDEPTH L�/ 9RE_3�•' NUMeER—�L_DISTANCE 7o NEAREST:WRL FOUNDATKIN��PROPERTY LINE_M. iUMFS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE :S DISPOSAL PONpa ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST!WELLFOUNDATION PROPERTY LINE ` I HERESY CERTI HAT 1 HAVE PREPARED THIS APPLICATION AND TH HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES # ANDREGU IOTI80 FH E SAN JOAQUIN COUNTY.HOME OWNER OR AGENT'S SIGNATURE CERTIFIES THE FOLLOVNNO:"I CERtIFYTHAT IN THE PERFORMANCE OF T14EWOW FORWMCN THIS PL IT 16 ISSUE I SHALL NO ANY PERSON IN SUCH M R AS TO BECOME SUBJECT TO WORKMAN'a COMPENSATION LAWS of CALIFORNU„^ CONTRACTOR'S HIRING OR u E 6UB�0 MCTINO 61 C I IES T FOLLOWL ERT THA IN THE PERFO CE OF THE WORK FOR WHICH THM PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORK AN COMPEN AT N F CAU RNIA.^ TP MU* CALL 24 NOV"IN ADVANCE FOR ALL REOIARED INSPECTIONS. COMPLETE DRAWING BELOW, _ I .I SIQNEO iME:_` DATE: PLOT PIAN(DRAW TO SCALEI SCALE is 1 7.NAMES OF STREETS ROAD EAAESf To OR BOUNDING THE PROPERTY. s. LOCATION OF HOUSE SEWAGE DISPOSAL 8Y87FM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANWON OF SEWAGE DISPOSAL SYSTEMS. 7- DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND IMPOSED STRUCTURES, S.LOCATION OF WTUS VWTHrN RADIUS OF INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS. HIINOREO FIFTY�•ON [j1 ji_ _...,,, „...... ....:..: NG PROPERTY ONE Ijc� I .T . I "-t �ps i /ctt /¢ s EFra14`} . r ,-.. ..,... _ _ �f- ry�tyLkpL��Ipy - .... .. „v...... ., ..., -j --- - t= �`jPiE l'R11J14i ..,,...... fi ... . ...o..... ..,.,... ....:,. ... - I ryj-r� FOR DEPARTMENT USE ONLY -J F. APPLICATION ACCEPTED BY J.ri_ ._. ____ DATE: N AREA: A 11S-- TAMC,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY ADDITIONAL COMMENTS: F < � ACCOUN7IN0 ONLY: AOD:I FACS I I �T 02PE -10FEE INFO//� AMOUNT t'-O CH RECFI �O LV aR 1F0aWT NVMa9i INVOICE 0 lJ3p-g R{f i