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APPLICATION FOR LIQUID WASTE PERMIT SArrJOAOUIN COUNTY PUBLIC HEALTH SEFETICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 /�� / / (209) 468-3420 0aI�/ / ��' /�Q NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lJ (Complete in Trblieab) APPLICATION IB HEREBY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE M COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 ANO THE STANDARDS OF SAN"AMIN COUNTY MOM HEALTH 6ERNW M ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESB/OR APN# iy 3 z- �b�- �Z'Qr--�yi.I^CAL� /J/J 1,1 IC,rry �M(f 1z7p7J LOT SIZE 2 iKPB OWNER'S NAMES77',6L1'� IJ C ADDRESS 13 30 Al /J/'—��W,T I S/ "C��J7J�J C PHONE Y(.tJ 6' CONTRACTOP�Dt-00� `y�'A S�STU C. ADDRESS ZZ J, �']f1A.S 7UZ (/A) #ICI J L1 CJ 1 V PHONE 6U0 CONTRACTOR AGGRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTAJkTIOM REPAIR/ADDITION ❑ DESTRUCTION ❑ MO SEPTIC SYSTEM PERMITTED IF PUBLIC 6EYJER IS AVAILABLE WITHIN 200 FEET Of BUILDING.) PEFIC TESTbI I 1 HOW MANY / Apo—"..I INSTALLATION WILL SEFIVE: RESIDENCE❑ COMMERCIALS OTHER 11 NUMSEA OF!VINO UNITS: NUMBER OF BEDROOMS'(( NUMBER OF FMROYEEA: 1 CHARACTER OF SOIL TO A DEPTH OF G FEET: G 1" MIBUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKNIEABE TRAP ❑TYPUMFG CAPACITY NO.COMPARTMENTS MG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER am ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPEPTY UNE MOUNDED 13 WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE INTO ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDAMN PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAMIN COUNTY ORDINANCES AND STATE LAWS,AND FLATS AND REGULATIONS OF TNF SAN JOAOUIN COUNTY.NOME OWNER ORUCENBED AOENT'O SIGNATURE CERTIFIES THE FOLLOWING:'1 CEPTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHOH THIS PERMIT IS IBBLIM.R SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION"WOOF CALIFORNIA.- CONTRACTOR'S MINING OR SUBCONTRACTING BONATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POP WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUILIECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CULL 24 MURAL IN ADVANCE FOR ALLAEOU REED INSPECTIONO. COMPETE DRAWING BELOW. SIGNED% /7 / 1 TITLE, — I C .Y L ti< </ DATE: PLOT RAN(DRAW TO SCALE)SCALE_ 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE ROPEHTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OP PROMISED 2. OUTLINE OF THE POPERTV,WTTH WMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED ARAB CN AS PATIOS,DRIVEWAYS,AND WALKS. THE ROPERTY OR ADJOINING PROPERTY. P3UILDIIJ� �i'LEHonI z� w D� G . Tn PARK NEfLEj. .il �w'KfC �rzAr-AGE �- PC�LO�A71oN R2 T 6A716 TEST ItoLC IwA no .. _ _ `AN Jua;9,l\,C3L PUOLIr C . - •H-AL711 SE'rVIC N 1.... _ AIM1ipN7AC IrN7 n,7I. \ / _ L7 F R OFP �UBE ONLY IL11 -` AFCA0N ACCEPTED BY � \ DATE ARA: c— TANK.M OR HUMP INSPECTION By \^ DATE / I FINAL IIN�ISSPPEECTION BY GATE A001TIONAL COMMEMB: �� Y/� p` �Lo ACCOUNTING ONLY: AIDI FACS pi UN 70 IN PECODE FEEINFO AMOUNT REMIITED CHECK/ ASH PECEVED BY DATE SA/PERMIT NUMBER INVOICE# lipwilli Pub.Heelm Sery.-Envlro.174(3/96)