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APPLICATION FOR LIQUID WASTE PERMIT L SA JAOUIN COUNTY PUBLIC HEALTH Sf 'ICESENVIRONMENTAL G \ LTH DIVISION 304 EAST WEBER AVENUE,,SSTOCKTON, CA 5202 (209) 468-3420 00 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComPlan In TrIPIkEtEI APPLICATION IB HEREBY MADE TO THE RAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCWBED. THIS APPLICATION IS MADE IN COMMANCE WITH SAN "AMIN COUNTY DEVELOPMENT TITLE.CHAPTER-78-f1110.]AND THE STANDARDS OF SAN IOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE6SIOR APNE iy3 Z- �/b ' rrHerTYU62 1I /J ^ Ic'm 'f�7�G/17(�7J LOT WE OWNER'SNAME /C�,L'EM-PJ _H C ADDRESS 1 3!� N1- !JP[-P�GJ�T] ♦S/ `�C%CTLT� PHONE T7? :O-Z- �JnI CONTRACTOR16L 1/�I�-a ) t SS DJC. ` ` ADDRESS ///IT'l.S 7v'pI L/,/ LIC, II TI U L" PHONE _�� r--3 SUBCONTRACTOR ADDRESS LICA PHONE TYPE OF SEPTIC WORN: NEW INSTALLATION REPNR/AODITION ❑ DESTRUCTION ❑ / IND SEPTIC SYSTEM PERMITTED IF POSUC SEVER 16 AVAILABLE WREHIN 200 FEET OF BUILDING.) P61C TESTI.,I I HOW I `gP/ AppMutlon, INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER ❑ NUMBER OF"NO UMTS:_ NUMBER OF BEMLOOMT/ NUMBER OF WMOYEFS: ' CHARACTER OF SOIL TO A DEPTH OF J FTET: L /A PITIBUMP MIL CHARACTER: WATER TABLE DEPTH SEPTIC TANXGREASE TRAP ❑TYPE M CAPACITY NO.COMPARTMENTS RIG TREATMENT PLANT❑ DISTANCE TO NEARUT: WELL FOUNDATION PROPERTY UNE UFT STATION Cl SIZE TYPE OF PUMP RAND OIL SEPARATOR IENCLOSED SYSTEM) UACNNO UNE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE FILTER BED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑MOTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DIBTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL MNDS ❑WIDTH LENGTH DEPTHS DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE - I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIER THE MUOMNG:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 MAU NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAW*OF CALIFORNIA- CONTRACTOR'S HIRING OR SUB-COMMCTINO MONATUM CERTIFIES TIRE FOLLOWING: 'I CERUFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IBBUEO,I SHALL EMPLOY PERSONS SUBJECT TO WOTKMAN'B COMPENSATION UWS OF CALIFORNIAn.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPETE ORUWINU BELOW. SIGNED X / ' / C� TITLE: C I L' -..i,, N c </ DATE: PLOT RAN OH/1W TO SCALE)SCALE_ -tO 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PMPERTY. C. LOCATION OF HOUSE$MADE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE FIHOPERTY.MRH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND ROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADRI6 OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREA84VCH AS PATIOS,DRIVEWAYS,AND WAlXS. THE PROPERTY OR ADJOINING PROPERTY. -41 �j Dr O G PARKPjiNG/ HERE c vy� _URPNG� _ �- PC�CO�A71oN R2 7-i GATE TEST hole (� qc OCTI41 AN Air Jvr'>J J +�Q N61�It4i .,JAI f PU j {c!!,L7FIS I Ilpn MIS OPF �OSY ONLYLA „ AP1KATroN ACC[PIEO SV 1 A ( Y DATE' U AREA. 1N ,Pl OR*UMPMMC1gI1 SV our NMu rtg *.EcrN*v OAIE U /5 K Tn Ip ARS1gHAl COMMUNIS G p� Flo MC0111FIBIY CULT AS,I LACI ' AU M R[CM FF*K!C M/,EUE S�1 TSR MRN YY SIfShM*'N EI*A EB RFIIE UH�/w EF,IMB I T ROE NNe�HS,5Y, E DMPP 176 LA1M0