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APPLICATION FOR LIaUIO WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE,'STOCICTON,CA M20i_W <br /> (204)48113420 <br /> KOK•REFUNI]ABLE PERMIT EXPIRES 1 YEAR FROM PATE ISSUED <br /> APPLICATION IB HEREBY MADE TO THE SAH JOAO ViNCOUNTY FOR A PERMIT TO COGNSTRUCT ANDIOR INSTALL THE WORT(bESCRIDEC.THIS APPUCATION IS MADE IN COMPLIANCE WITH SA <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.3 AND TIIE STANDARDS OF SAN JOAOUM COUNTY PUBLIC NFALTM SERVICES,ENVIPpNMENTAL HEALTH DIVISION, <br /> J05 ADDRE66'OR APNA q,7;2 I CC 1,A2 IS/1'I fSU ,Q ORO Dlry CA t <br />,{ { OWNER'S NAME II t of P-ex el-)D —"" �I`°T�` t—r <br /> IIIII 'J7 ^�'� ADDRESS ,1 PHONE <br /> CONTRACTOR- /1� L'a•'1RG1t.C. ADDRESS l I�L�J HSI[ q p p <br /> LICI 11 j O PHONE <br /> SUS CONTRACTOR ADDRESS <br /> PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIRI&DTMTION DESTIIVCTION❑ <br /> INO SEPTIC SYSTEM PERMITTED IT PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SI111.DINC.I <br /> PLYIc TESTUI[]HOW MANY <br /> I--� <br /> Appilo,8oe 5 <br /> INSTALLATION WILL AERVE: RESME.NCE 0 COMMERCIAL OT IlFR v__ <br /> - <br /> "WEIRS OF LIVING VNITA: Fit"REIR OF SEORODMS:— r N�SER OF SMPL,O%EEA:_-Y <br /> CHARACTER OF SOIL TOA DEPTH OFF�3 FFFT: C0 0 - MTISUMP SOIL CHARACTER-�WA7 ER TABLE DEPTH <br /> SEPTIC TANKIGPIEASE TRAP [I TYF£IMFLi �L CAPACITY� <br /> 1--� �^ NO.COMPARTMENTS _ <br /> PKI TREATMENT PUNT C7 DISTANCE TO NEANFtT: WELL�1 1J FOUNDATION S 1 <br /> . PY<OPERN UHE`� <br /> UFT STATION❑ SIZE TYPE OF PUMP SANG OIL SEPARATOR(ENCLOSED SYSTEMI <br /> LEACHING UNE 0 NO.A LENGTH Of LINES DISTANCE TO NEAREST:WELL <br /> i FOUNDATION E710PERTY LINE <br /> _,_-,T <br /> r FILTER RED 0 WIDTH LENGTHDEPTH DISTANCE TO NEARSI WELL E ' <br /> 1 FAUNOATLOH PROPERTY UNE <br /> MOUNDED 1❑E WIDTH LENGTH DEPTH DISTANCE To NEAREST:WELL FOUNDATION PROPERTY LME <br /> SEEPAGE"T5 E]DEPTH SIZE NUMSFR DISTANCE To NEAREST:WELL FOUNDATI N <br /> p PHbPERrY uHF <br />}� SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST WELL FOUNDATION PROPEPTY LINE <br /> II/Y'I j DISPOSAL PONDS <br /> WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> HEREBY CERTIFY THAT E NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAH JOAOUEN COUNTY ORDINANCES AND STATE LAW/,AND RULEg 1 <br /> AND REGULATIONS OFTHE SAN JOAQUIN COVNI HOME OWNEROR LICENSED AGENT'S SIGNATURE,CERTIFIES THE POLLOWING:'I CERTIFY ONTY ORDINANCES <br /> rATEE AWS.OMK AND MACH I <br /> THIS pEPM17 is ISSUED;1 SHALL NOT EMPLOY AMY PERSpN IN SUCH A'MANNER AS'TO 4FCOWE SUBJECT TO WpPKMA#1'S COMPENSA71ON CAWS OF.CALIFORNIA:''CDNTSACTOR'8 FRN1l0 OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FCtLOWING:-I CERTIFY THAT iN THE PERFORMANCE OF THE WOR(FOR WHICH TNIB PERMFf.15 ISBVEO,1 SHAM EMPLOY TAACTPEWF MINING)RACT TO <br /> wOE+IKMAN'S COMPENSATION LAW/S/-�pF CALIFOR A.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE Fal A/L;�RE�W�REyO�WSSEcriON/. COMVLETE DRAWING/BELOW. <br /> SIGNED k ✓'r! �--J - TITLE:-�IJG.V"[.J�_ <br /> DATE: ! <br /> Imo` PLOT PLAN MRAW TO SCALE(SCALE '-le <br /> 1 <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, s. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM pR RgIVS{D <br /> !!!L 2.OUTLINE OF TIIE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. LOEXPA TIONSION OF OUSE S DISPOSAL SYSTEMS, <br /> ]. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND WCF06ED STRUCTURF9, S. LOCATION OF WELLS F DISPOSAL <br /> RADIUS ST ONE HUNDRED FIFTY Orr.ON <br /> INCLUDING COVFRED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIx8.. .THE PROPERTY OR LS WITHINADJOIHING PROPERTY. <br /> iAslerz..p�1P,6 hl�TFS= SEE REvEr25E <br /> 1 7r+N r-s zmo I. r F 0 2 Dv�l I til G <br /> �fAc� x�sTluc q? ,�oLE,crs Sn►vr^rr L.*tA Ass <br /> 1Mk �1iIrT1I' �_ 5� taa}p 'Po IWS - ND 1414$ &,)I?. <br /> GE�t Sc�Pllr b) *uwL con3AhcTIOA-) $,Isba3T <br /> nLD '6€iTc TAIIJIL <br /> 't?dc ;Hcy u T� AtMP E ZAC.sCp1IIE0 <br /> I.r x�sr,N 56 � To 8) All arAE>Z CAIS"17N1- <br /> �..... . tlA1F5 F+[� ans+A•�'BEA�rr <br /> eeo.....:LCAc11 Grni.t 5... tX>00� Co.opLtfon.� i <br /> n k5._ <br />� K2.�Jye✓br I <br /> y' AN UFC <br /> .T/. ;..0 51111ti1 >f7 Pl <br /> HEAL <br /> tl , r1J�_ <br /> {d�k r^(GFS <br /> .... } v l pal i1 1 <br /> rNV4. <br /> iII FOR bEPARTMENT UAE ONLY <br /> T. ArPUCATION ACCEPTED BY DATE'- 17 <br /> 2 r AREA; H <br /> TANK,PIT OR SUMP INSPECTION SY DATE I / FINALN BY DATE a-7f <br /> y <br /> i� <br /> ADDITIONAL COMMENTS; y 1 )i <br /> lL �cL.0-L h. h-- h.G j,q, Vl.t- 0�- <br /> ACCOVN71N0 ONLY: �Rwmilll. <br /> FA61 <br /> PE CODE FEF INFO AMOUNT DNEC 'CASH RECEIVED BY DATE SPL EPESVr51T NUMD61 INVOICE f <br /> a50 <br />