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APPLICATION FOR LIQUID WASTE PERMIT CiI.J -T.. SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION :S�'-y(E+' G 304 EAST WEBER AVENUE,STOCKTON,CA 952 ANTI Zoy-09 -iy, (209)468.3420 $v,R-U�tl�i PrkM1 MON•REFURDAREE PERM T EXPIRES 1 YEAR FROM DATE 11SUED �j�CX��g I' r."wbtl In Tfoliaul APPLICATION IA HEREBY MADE TO THE SAN JOAOUIN COUNRT'FOR A PEE,EIT TO CONSTRUCT ANO,OR INSTALL THE WORK DESCRIOM. TNN APILCATMW NI PLJANCf YWTH SAN JOAOUN COUNTY OEVROPMENT TTTLE,cNAITER 1.1110.3 AEA THE STANDAP—OF SAN JOAOUIN COUNTY RACK HEALTH SERVICES,ENVNOFNO/TAL HEALTH DMSON. JoaAD /Broa ,w/ AP Ilc,1��1 {KE�T- �:F•,Ataj-iNF koAU (CriL, 4{) cm -MAc`! ROTI¢E DIE OV.REn'1 NAME F'.A L.'l. E^A C.HAADDESS PHONE�g•t)Z`:/.."q E.4c,: fYc� < Anowns �'tF^. �4AT1-EYi tLAZF1 LJDP IIT�AA- FNLNE(2c5)�4R-41� Wil CONTRACTOR ADDRESS IJCF AgNC TIFF OF SV WORK: NSW INSTALLATION❑ RVNVADDIHON❑ DESTRUCTION❑ [NO SEPTIC SYSTEM FERMrREO F MJSUC SFWFR IS AVAILABLE WTTHN TOO FEET OF EUIIDNEO.I ERIK T-TRHyj MOW MANY r'El2�.n.f S.014 Y'E:LT APFIo.INI P_ NETAI-AYMN WRL SINE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ :--OF UVNG IRETS: NWSSL OF SOIIbM OS: NU UM OF VAPLOY4J: HUCTFR OF SOTO A DEPTH OF 3 PQT:_ PrtANMP SOIL CHARACTER: WATER TNLE OEPT MS. Ir- 1VTHC TAREA KUI TRUC-E ❑TYmw-I CAPACTTY NO.COMPARTMENTS POLO TREAYMERT PUNT❑ OISTANCI TO NEARFRT: WELL FOUNDATION PFOPE701'IMF LFT STATION❑ 112E TYPE GF PUMP SAND OIL SEPARATOR MWLOSEO SYSTEMI _ LEACIwHO INE ❑ NO.•LENGTH OF LINES_ 0101ANCE TO NEAREST:WFU FOUNTATON PYOEERTY LINE ALTRI 1® ❑WIDTH LINOTH_ DEPTH DHSTAMCE TO EXAREBT:WELL POWDATON PRDI ERTY LAW MOUNDED ❑WORN LDNOTH__DEPTH DISTANCE TO NEAREST:WELLH'ANDATOM PR oolp Y UEE SS>EAQI FITS ❑DEPTH SRF--NUMBER DISTANCE TO NEMESTr WELL FOUNDATION 1/OPEFITY LYE SUMPS ❑WIDTH LENGTH _DETTH DISTANCE TO NEAREST:WILL--FOUNDATION PROPERTY LINE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH OCTANCE TO WARIEST:WELL._FOUNDATION RROPERRY UNE 1 HERESY CERRIPY THAT 1 NAVE PREPARED THIS ARLCATION AND THA,•THE WORK WI L N DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORONANCES AED STATE LAWS,AND/FRES AREMOULATONI OPTS SAHJOAOUNCOUHTY.HOME OYMIEI OR LCDMED NERY MONATURIECERTREI THEFOUL(r~;'ICETOIFY THAT NTNE PFPEOREAANCE OrTHEWUPK MRWNICN ~ TMS FEEET 18 ISSUED,1 SHALL NOT EMPLOY ANY FERRITE N SUCH A MAANER M TO BECOME SUSJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONNTRACTWTS HIRING OR 4:7;_ SUB-COMMCTNO WON TIM CSAR/ES THE FOLLOWING:1 CERTIFY THAT N THE RNORMANCE OF THE WOW FOR WHICH THIS FUNIT IN ISSUED,1 MSALL ORIOY PFFVK*M RIBJECT TO WOIKMAWS COMPENSATION LAWS OF CAIMMMA.' THE APPLICANT MUST CALL 31 HOURS N ADVANCE FOR ALL REOLIS11111)NYECTOMS.COMPETE DMWSNO BELOW, J � Zi "(i`✓ 1 A, n. TrrLE� .�IyI L DATE: PLOT PUN DIIAW TO SCAM CALF_ Is 1.NAMES OF STREETS OR AOADS NEAREST TO OR SOUMIYG THE PROPERTY. S. LOCATION OF HOUSE SEWAGE OISPOSAL SYSTEM OR PROPOSED 7.OUTLINE OF THE TMEP OPERTY.WITH D INONS AND NORTH OEC RTTON. EXPANSION OF SEWAGE DISFOSAL SYSTEMS. 3.OWD400MID OUTLINES AND LOCATON OF ALL EXISTING AND PROPOSED STRUCTURES, 1.LOCATION OF PALS WITHIN MENS OF OM HUH0IEO FIFTY FT.ON \ INCLUDING COVETED AREAS SUCN N PATIOS,DRIVEWAYS.AND WALKS. THE P'ROP'ERTY OR ADEOMNO PRIPERY. .SJ SN �Yal� �r1lCT'. i . f-f13 219 ............ . ... ... .....:... ..... . • 9 • . : snri Iuhoi;;ru c�.vAr: . . .. .. -PIJeUC H6{;;fN 9EPVI29 . . ....ENYILIONMEM.'.1.�:a;pU jE bW,M1••.; FOR OEPAPTTIDRT USE ONLY APR1LAilON ACCEPTED BY DATE: /� �� NEA: Q TNR,PUT OR SUMP NYSCTION SY DATE I I FINAL N—CTDN D' DATE ADDITIONAL COMMENTS: / r l �A L%, !{L/L.Nt•% �7/1 b1,[ MCOUIIIYAO ONLY: AS)/ PALS R CCOE RINFO AMOUNTREEITED A:ASN RECEMtD SY DATE S11l PSV1ET 141.00131CE I INVOIS ; 71' E Put).H/etth Sere.•EJ•1YEro.174(3X6)