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IMPLICATION FOR LIQUID WASTE PERMIT %-!:0 JOAQUIN COUNTY PUBLIC HEALTH SERVICES�J ENVIRONMENTAL HEALTH DIVISION C U py P.O. BOX 300, 446 N. SAN JOAQUIN ST., STOCKTON, CA 9620103 (2091468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (OBmPIetB in TrOlieBb) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VOW(DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY OEVEIOPMEHT TITLE,CHAPTER 9 1110.3 AN''DIIT14E STANDARDS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH UMBiON. .TOR ggoRFssron nPNP f S O L H 4Y I G H Q I1WHEII'A NAME T 1' �• LOT SIZE__ —S—JL�-C-VF n/`��VS1" ADDRE9S .`J cA Y y PHONE It / -I .^ CONTRACTOR "Y'�-� �NOSL,L.ZI.YLCLADDFE86 �JE J/� F� 'eC f,t. t kT- UCI 7t) PHONE (tC J" 200 FDA CONTRACTOR_ Q AODRE88 -�(YV �L 1✓4�Son LVCj,�I LICE zs`t3y3 PHONE Y& -% 7 T YPF.OF SEP EIC WORK: NEW INSTALLATION Is REPAIR/ADDITION ❑ DESTRUCTION ❑ y I O SFPI IC Syr"MMI?TED IF MW IC SFWFR IS AVAILABLE WITHIN 200 FEET OF SUILOING.1 RIC TEBTNI 1 I HOW MIRY bnEAeePp R INBIM-UNION Wlll-6DiK.: RFSIbENCE❑ COMMCIICIAL�15( OTHER 11 N1A91DI OF IIVINO UMTS:__ NUMBER OF BEDROOMS: NUMBER OF EMROYEE):t- CH.ARAC IES OF nORI TO A IHPTH OF J FEET: Ml'/SUMP SOIL CHARACTER: WATER TABLE DEPTH FlMll I nH!:IMIFn IWO TRFAIMrNT M INT I•] DISTANCE TO NEAREST: MIL FOUNDATION O.CO,TYUWI RIFT STpT1UN SRF TYPE NE OF PUMLP��BAND OIL SEPARATOR(ENCLOSED SYSTEMI (^ IFADIENR USE 10 NO.B LENGTH OF LINES l-S \ SO�F DISTANCE TO NEAREST:WELL UCS( FOUNDATIONS PROPERTY UNE V o E4 HtIEq PFU ❑•WIDTH L(NGTN OFPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MPRINmr• 0MOT II_ LENGTH 'IFPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY USE L• n 1-I IIIITH____ M2E ___WUMBIR DISTANCE TO NEAREST:WEIL FOUNDATION pnopERry UNE O RII.MF'S L]WIIIIII LBNGTII DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ^ , "HM6.L PONOS ❑MOTH—LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE [V_ T,UnvT(•RFPAREO THIS Al'CATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY OIIDINANCES AND ETRE LAWS,AND RULES V nbn N•�•i p•"o" ^: vP B....P"OUIN COUNTY.HOME OWNER OR LICENTIEO AGENT'S BIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW MR WHICH Pu:M"'+u I I." r,I•B IAT 1 IRTT EMPLOY ANY PERSON IN SUCH A MANNER A9 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR r r i. ,,,;q,.,l PPF r'FHTII'ITS THE RTI LOWWD:'1 CERTIFY THAI IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.I SHALL EMPLOY 1111011 SUBJECT TO •J`,,,OU I AWB or C('AAIII IIFFFOOOHNIA.- CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIREI INSPECTIONS. COMPLETE CRAVING BELOW. .Il.rlTli C/' t U , TITLE: DATE: H �, PLOT RAN(DRAW TO SCALE)SCALE to In HDAUS NEAREST 10 OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P1OPOIS IfN I HTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. TED -A),OCA S PA IO A11.EXE^.TINS ANDWAHOSPROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RANUB OF ONE HUNDRED FIrTY M.ON oDC11 A9 PATIOS.DRIVEWAYS,AND WAUte. THE PROPERTY OR ADJOINING PROPERTY. � cc c, - J(1 y V so Ii Ile S J PAYMENT RECEIVED s 8 0 MAR 31995 U �/'// SAN JOAQUIN COUNTY 41 "', Z (' ArE<� LI( HEALTH St LiVICES �� 101 l of 6q """' NMENTAL HEALTH DIVISION "•'Gw �3 L N-tev.1 oz o 0 v 1260 qk6" 140 I �i / s ENT USE ONLY At uu (•T Il4,N q[C! EO DY L.+ Lj/�L"fY/CCbbC ss J�'0 !� GATE: AREA: TANK,RT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION SYa DATE,-? AOIIIIRRA1 COMMTNTS: ACCOIINDNn ONLY', gIDI FACT P�CODE FRF.two AMOUNT REMITTED HEC MASH RECE BY DATE SIR P TNUMBER INVOICE IF 't"Pe ../