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APPLICATION FOR LIQUID WASTE PERMIT SAiv JOAOUIN COUNTY PUBLIC HEALTH S_ACES U ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CampletB in Tripbuts) APPLICATION 18 HEREBY MADE TO THE BAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORE(DESCRIBED. THIS APPMATION 18 MADE IN COMPLIANCE WITH BAN JDAWIN COUNTY DEVELOPM�ENET TITLE.CHAPTER 9-1110.7 AND THE STANDARDS OF BAN JOAQUI N COUNTY MOM HEALTH SERVICE B.ENNRONMEMAL HEALTH DIVISON, JOB ADDRESSOR ATYI/.t ♦�,f ��'`'`r tru c�+— y�+/f� crry 5 G«�✓1 Lor SIZE -7 OWNER'S NAME n oVI14'IL(� I T LL �Cl ADDRESS 7M ALONE Illss-L(v9- R33L( n �.�E�.11� 7 7 C.NTRACTOR��^tC`E, rf&It[1\ ADDRESS PLS /,J<lx 'J �� lKF �l PHONE2yl ' 7,3 SUB CONTRACTOR ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIIVADDITION ❑ DESTRUCTION ❑ ING SEPTIC SYSTEM PERMITTED IF MOM SEWER IS AVAILABLE WITHIN 200 FEET OF BUtLTKNGJ PERC TESTI.)I IIFHOW MANY �/ App6PEtlon.^/9— 5 IGS S-4 INSTALLATION WILL SERE: RESIDENCE 0 COMMERCIAL Ad OTHER ❑ NUMBER OF WINO UMTS:_ NONCOM OF■EDROOMS: NUMBER OF EMPLOYEES: e CHARACTER OF SOIL TO A DEPTH OFF�3/FFTTT: CT 1MTRIUMP SOIL CHARAER: �]P>'1CJ_ WATER TABLE DEPTH REPRO TANIVAREAGN TR�AP1 ROTYPE/MFG Pt CAPACITY Ia-OO NO.COMPAMMEWS .0 TIVATMWT PLANT IJ DISTANCE TO NBME/1: —H - L46l, 101)111 AIIUN G' MMIHHI V LIII[ I)I Yff pXHORM LIFT NATION 11 o"NO.B LENGTH OFTUNES F I P_ti O F RAPID OIL SEPARATOROI TB PE TTO NEAREST!YWELL 1 FOUNDAI.N PROPERTY UNE LEACHING ONE o" No. BED 0 WIDTH LENGTH DEPTH dBTANCE TO NEAREST:WELL FOUNDATION AIOPERTY LINE MOUNDED ❑WfWIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE_ SFEPAOE RUlm" ;.5- SIZE 3 C NUMBER DISTANCE TO NEAREST:WELL FOUNDATMN_3�!_PROPERTY ONE 30' SUMPS D WIDTH LENGTH DEMO DISTANCE TO NEAREST;WELL rOUNDATION FROPFATY UNE DISPOSAL PONDS ❑W1DTI1 UNOTII DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P10PERTYLINE I HEREBY CERTIFY THAT 1 HAVE PREPARED TH18 APPLICATION AND THAT THE MW WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND PEOULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER ORUCEN IED AGENT-8 SIONATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIR PERMIT IS IBSUED,1 WALL NOT EMPLOY ANY PERSONW SUCH A MANNER AS TO BECOME BUBJECT TO~WMAN'R COMPENSATION LAWS OF CAUFOIWIA.' CONTRACTOW S HIRING OR SUB.CONTRACTINO SIONATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 WALL EMPEOY PERRONB SUBJECT TO WOWMAN-S COMPENSATION LAWSOF CA10'O,RRNI/FIAT.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL"GUAM INSPECTIONS. COMPLETE DRAVMNOrSELOW SIGNED% � \ /�Af TH : `-O N1C['Y'n ^ DATE: ` (A '('k yP`"'T."�' POT PAN(DRAW TO SCAS)SCALE_ -10 1. NAMES OF STRUTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE NS OSAL SYSTEM OR P10P.BE0 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINEO AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WHHIN A,LNU6 OF ONE HUNDRED FIFTY ff.ON INCLUDING COVERED AS OUCH AS PAMS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ♦ 1r 0 0 O C\ PAYMEW JAN 2lltitC SAN PUpU(:F A(JUIN _. _... "NVIRONMF ALFIE41 RV II CVISn FOR DEPARTMENT USE ONLY A ATION ACCEPTED By DATE: � A' / ('Ll`C/-'//qy,) T�OR BUMP m6PECTI0N By DATE / / INAL INSPECTION BY 04= ATE. I�_ � AOUTIONAl COMMENTS: ��i T ACCOUNTING ONLY: ADI FACF PE CODE INFO AMOUNT RIEMII�T .�DEFEE INFO AMOUNT REA ITE. CHEC ICA611 flECBVEO BY DATE SR I PBVAT NUMBER INVOICE E 2 �- 57 -5 Pub.Health Se, -Envlro. 174(3/96)