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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES L ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA SM1388 {2091 480,3429 P NON REFUMBLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;CamPMtB In Triplieatol APPLICATION 18 HEREBY MADE TO THE SAN JDAOUIN COUNTY FOR A PERMIT TO CCNSTRVCT ANDIOR INSTALL THE WOM DE9CRIOEO,THIS AP"ATION IS MADE IN COMPLIANCE WITH CAN F110. JOAQUIN COUNTY DEVELCPMENTTITLECRA/PATER8-111D.3 ANOOTHEESTANDARDS OF SAN JOAOUINCOUNTY PUBLIC HEALTH SERVICTS.ENVIRONMENTAL HEALTH OIVISION. ADDRESSOR APN1, % LJ ��/�7 �%r - CfE'r G LOT SIZE OWNER'S NAME / Ap OHE95 CONTRACTOR_ _ ADDRESS ;L>O, 1,SUB CONTRACTOR ADDRESS LIC• PHONE TYPE OF SE►TTC WORK: NEW I/faTALLATTDIE❑ PEPMFIIADOOJON DESTRUCTION E] IHO'SEPTIC SYSTEM PERMED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BVILDING.1 PMC 7FATp,1 17 HOW MANY F.- APdb-lf—S STALLATOH wql aL75VE: RESIDENCECOMMERCIAL{_ OTHER nUMB TTI OF UVINa UNtTE; NUMBER OF BEOROOMF: IIUMSOR OF EMPLOYEEST CHARACTER OF 801L TO A DEPTH OFFE'33q�FEET: I — PTTISUMR SOIL CHARACTER:.4-An�Jac- WATER TABLE DEPTH SEPTIC 7ANKJORFASE TRAP UTYPEIMFO CAPACFTY 6/�'iG T.:)� NO.COMPARTMENTS— 11 PXG TREATMENT PLANT DISTANCE TO NEAREST: WELL �'T FOUNDATION �_ PROPERTY LINE_ 7- _- LIFT STATION❑ TTZE TYPE OF PUMP BAND OIL SEPARATOR IENCLOSED SYSTEM) `1 LFJICHINO LINECINO.&lENOTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE }` FILTER 1@ Pr WIDTH LENGTH 5r DEPTH 115// DISTANCE TO NEAREST:WELLy612 Ff1UNOATIONPROKRTY TINE4:2 . _ O UN D@ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r sE'SPAaE EFTS ❑ FOUNDATION PROPERTY SIZE NUMBER DISTANCE TO NEAREST:WELL UNOATIONPROPERTYLINE �VI. ❑WROTH LENGTH DEPTH DISTANCE TO NEAREBT:WELL FOUNDATION PROPERTY"RE _ DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE _ V 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAH JOAOUIN COUNTY OROINANCE9 AND STATE LAWS,AND RULE; AND REGULATION$OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSEn AGENT'S SIGNATURE CERT'TFIES THE FDLLOWINa;•I CERTIFYTHAT IN THE PERFORMANCE OF IHE WOHL FOR WRICM THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWB OF CALIFORNIA.' CONTRACTOR'S HIREHG OR SUB.CONTRACTINO SIGNATURE CERTIFIES THE FOLLOMRHG:N CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PER90N9 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUPLS IN ADVANCF FOR ALL REOIAR@ IMPECTIONS, COMPLETE DRAWING BELOW. 31aNE0 Jf�l ..Gl TRLE: ROT PAN(DRAW TO RCALEI SCALE 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF TNF PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, V. IMENSIoNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS CF ONE HUNDRED FIFTY FT.DN i INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. -.- -. # ' a I VE - pAJrPnPF4 �. 114`�. .... .. -}L NOU.,.....6 1997... :.._. : . SAN JGAQU(N COUNTY ENV RCTvt11EN7Al.MEA LTE'4�SiOly FOR DEPARTMENT VIF ONLY F"Ll"'ON ACCEPTED 6Y caa.,14 a DATE: AREA: NK.RT OR 6OMP INSPECTION SY /^ /TA DATE E I I FINAL INSPECTION AY (1 OATS r ADDITIONAL COMMENTS: f}f(,(K 'Y1]V - I�.Y Lf zoo L7 0 -L, -LC ex to TH�I(Iti Acca VNTINa ONLY: AID. FAL. PB CODE FEE INFO AMOUNT REMITTED CHFC IC ASH RECEIVED BY GATE 8R I P]R1IT NLMY- INVOICE 0 57 �3s „ 9 1 y S oda ra