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1PPLICATION FOR LIQUID WASTE PERMIT O(l(G(�7 SA�OAOUIN COUNTY PUBLIC HEALTH SE,r:ICES {y� �_ ENVIRONMENTAL HEALTH DIVISION A 304 EAST WEBER AVENUE, STOCKTON, CA 95202 I(209) 468.3420 I q3 _9�V OV MOM-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICBmPMto In TFIPIWtEI APPLICATION IB HEREBY MADE TO THE SAFJ JOAMIN COUNTY FOB A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WETH BAN "AMIN COUNTY DEVELOPMENT TRUE.CH--A7P_/T/EN 9.1110.3 AND/�THE BTMIUAM6 OF BAN JOAOUIN COUNTY PUBLIC HEALTH BERVKEB,ENVIRONMENTAL HEALTH DIVm1ON, JOB ADUPES6OR APN! f y 3 Z 7 b l Tel^-�V : elry STDG/17Zl � LOT KZE J/2 iK // OWNER'S NAME^^'f ,, CLJ f0-A1 N C 1 ADDRESS_)33U--E - MJU 5 7 NU- /j/La�1'DGLI/4'y S7aCJ(CTI/�( PRIONS y��li' �UO� CONTRACTOR Alln�SRI 1 r - S;D�. ADOERE68 2 �� LSI 5'1 CJ I G PHONE BUS CONTRACTOR ADDRESS LIC! BONE TYPE OF SEPTIC WORK: HEW INSTALLATION REPNNADDITON ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUILDING.) PERC TESTI.,1 I NOW MANY I1pPYwtlnn! INSTALLATION WILL SOME RESIDENCE❑ COMMERCIAL)d OTHER ❑ NUMBER OF UVIMG MATS:_ NUMBER OF BEDROOMS: NUMBER OPER EMR CHARACTER OF SOIL TO A DEPTH OF J FEET: L t A PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANAXSIEASE TMP ❑TYPE/MPO CAPACITY NO.COMPARTMEHTB Mo TREATMENT RANT❑ DISTANCE TO NEJUEST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR[ENCLOSED SYSTEMI LEACHNO UNE ❑ NO.S LENGTH OF UVEB DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL MUNDATON PROPERTY UNE MOUNDED ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE FITS ❑DEPTH SIZE NUMBER DISIAHCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SU NIPS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEARl MELl FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIED THE FOLLOWING:'I CERTIFYTHAT IN THE PLPFOIMANCE OF THE MW FOR WHICH THIS PERMIT IB ISSUED,1 814 LL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA- COMRACTOR'S HIPNO OR BUGCONTRACTINO SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I BHN,EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CNUFOMIA.- THE APPLICANT MUST CALL E4 IOIIIRS IN ADVANCE FOR ALL REQUIRE(D�INSPECTIONS. COMPLETE DRAWHG BELOW. SIGNED% 1� Com---� TRUE: C t I lr DATE' ROT RAN DRAW TO SCALE)SCALE_ -1° 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OHIFOGAL SYSTEM OR PROPOSED Z. OUTUNE OF THE PROPERTY,WITH DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEAS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EILISTIND AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVEPEO AREAE- CH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING ROPERTY. kUlLninlc j BUI1 UI�G w �A MED G lilt- PAizK �7j�, NEILE C 4A/14_ < � � C ()1ZAr1GE 1� TL�COLATIOt, ^^ GATE _ TEST ICDI,C �Y OCT,1 4. _. _. At.i A?) )k cey(,"v PUOUG HqA�TN S1:YTV1 NMPN'FA[ rfFAlt 'nrll l IT F .GEP USE oMtr .` r \ 11\ DATE. U AREA APPLICATION ACCEPTED BY �e TNA(,FIT OR BUMP INSPECTION BY (T CIL, \/I DATE / / FINAL INSPECTION By GATE UI ADDITIONAL COMMENTS: ` Tri L /D•Y'�44 � 20 7�s7�'Y°�E ACCOUNTING ONLY: AD! FACE n IN /O qy PE CODE FEE R.M AMOUNT RETJIIITED IIECK! ASH RECEIVED BY DATE INVOICE I M/PEVAIT HUMBER a 2 � Pub.Health Sew,-Enviro.174(3/96)