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i j APPLICATION FOR LIOU111 WASTE PERMIT SAN'JOA(IUIN COUNTY PUBLIC HEALTH SERVICES !. tNVIRONMENTAL HEALTH 111VISION P.O.BOX 398,304 EAST WEBER AVENUE,STOCKMK CA 95201388 (209)4813420 U •REfVMDAB PRM EX RE! AFROIJ PATE 13SUED IEamplap ls'TrfplltaBl j APPLICATION 1S HEREBY MACE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR MIBTALL THE-O"K OESCRBED,THIS APPLICATION 18 MADE IN COMPLIANCE WAN SAN JOA.QWN COUNTY DEVELOPMENT TAL//E,//CYMAAPTER 8.1110.3 ANp THE STANGAROS OF SAN JOA/OLSN COUNTY PUBUC HEALT�H/S�EyR'V}p�CES,ENVIRONMENTAL H HEALTH DMBION. JOS AOOPEBCIOR ATNF - ( J 31/ J CC Crly-s.tylS.Lll1�2 �rLO7 SgEy 1 S Z { L .OWNER'S NAME - ADDRE8S �I/ PHONE - i '] CONTRACTOR&FA r ACO PE.-2 a LODI �•^ uDY FHnNE �I BUB CONTRACTOR ADDRESS UCP �• PHONE TYPE OF SSW=WORK: NZWZIALLATIOTO REFAIIVAdNT10N pFBTRVCTIOM Z] WO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER N AVAILABLE WITHIN I!OO FEET OF SURDIN0.1 FEIC TFA71. E 1 ROW MANY�� f AP'PPPSYeR E PNtTAUAT}DN WRL SFRYE: RESIDENCE�'.COWMERCIAfS�i OTHER 0 . NIIMSER OF WINO UMTS: NUMam OF BEDmodmd: NUMBER OF SMPLOYESS: CHARACTER OF SDR.7O A DEPTH OF O FEET: PITICUMP BOR CHARACTER; WATER TABLE DwrH - - E 11"TIC-TANRIOREASE TRAP ; ❑TYmmm." CAPACITY NO.COM►AIRMENTB 1! NLG TRFATMEfr PLANT 13 DISTANCS TO NP LRUT:. _ WELL FOUNOATION P�ROPENTY L1HE - - UFT STATION© SIZE TYPE OF PUMP BAND OIL SEPARATOR otmoBEO DYBrEMI . € LEACRNO UNa 13 NO.a LENGTH OF UNES DISTANCE TO NEAREST:wETL FOUNDATION PROPERTY LINE - FILTER CLO []WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL F'OUHDATION PwFERry UN£ 1 MOVNDLD (1 WIDTH LENGTH DEFT" DISTANCE TO NEAREST:WELL - FOVNDATION PROPERTYUNE SMAOF PITS 13 OEPTN SIZE_NUMBER DISTANCE TO NEARER:WELL 'FOUNOATgN P,mpERry UNE SGMps- 17 W1n7H LENGTH Dwm DISTANCE TO NEAREST:YYEI,L -FOUNOAnON PROPERTY LIRE DISPOSAL PONDS C]WIDTH - LENGTH DEPTH DISTANCE TO NEARER:WELL iOUNOATION PROPERTY UNE 1 I HEREBY CE RTIFY7HAT 1 HAVE PREPARED THIS APPLICATION AND THAT TME WORK WRL BE DONE M ACCORDANCE WITH SAIL JOAKRRNCOUNTY ORdNANCEB A"STATE LAWS,AND RULES i .AND REGULATIONS OFTHE SAH JOAOUM COUNTY,HOME OWNER OR LICENSED AGENT'S SIONATNRE CERTIFIES THE FOUDWWO;•1 CERTIF COLWr)TIB PERFORMANCE OF THEYYOR[TORVMMH - i THIS PERMIT R 186VW,I SHALL NOT EMPLOY AM'PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO VVOIRMAN'B COMPENSATION LAWS OF CALR-0RNIA.' COMMCTOR'S MFFpM OR SV"ONTKACTI%G SIGNATURE CERTIFIES THE fOLLO"Q;9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TNR PERMIT 10 ISSUED,1 VWL EMPLOY PfRBoNs SUBJECT TO b WOPKMAHCOM ATIOH LAWS OF CALL 1A.• THE APPLICANT MVST CALL N HOURS IN ADVANCE FOR ALL REOMEO INSPECTIONS. COMPLETE DFAWM10 BELOW. `rkF SIGNED X TITLE: + - PLOT PLAN WRAW TO SCALE)SCALE •is - T,NAMES OF STREIMS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY, 4.LOCATION OF HOUSE SEWAGE dBPOLML SYSTEM OR FibPOfEp € 2.OUTLINE OF THE PROPERTY.NST"Dima of t AND NORTH DIRECTION. EkP/WSgN OF OUSE E WAGE t L eYlTEM Y DR.1R1vom OvnINES AND LDCATNON OF ALL EXIBTMIO AND P1bpOSEO RRICTURES, LOCATION OF WELLS WITHIN MONIS OF ONE NVND11[O FX V FT,ON INCLUDING COVERED AAFA6 SUCH AS PATIOS,DRIVEWAYS,AND WALKS. E. EPA MEN PRDPEitI•Y OR ADMINRIO PIIOPEPITY, r... REC:EIVE❑ l AUG "1.24�� I..... ¢� gLD4.7 .. ARS ........ SAN JflA0l71N'GOUh#TY "''Pt16L1GtiEALT1i5ER�4GE5 p .. . ... :.,....ENVIkONMENT�;HEA€TH DIVISION ', L ............ ALl GF.: M1 ... _ - v . F t Y�Gf1 I L r m ...... ...... ...... F ...................... .... ...... L _J. l... . .. . . .., tAGri; . �a t E* Lm .............. ............. LL t............ FOR oeP ENT USE ONLY yy ((�} ++�� { AMLICATION ACCEPTER SY I l DATE: U V� AREA: TAMC,PR OR SUMP INSPECTION 6Y - DATE f 1 FINAL`INSPECTIpN BY - RATE__/- { AUDITIONALCOMMENTS: .._ ACCOUNTING ONLY: Alw -PACY CDOE FEE INF4AMOLWSTR TTED CN ASH REC aY OA E SR I FUMY IILMPaim INVOICE!