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i APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P-C, BOX 360, 304 EAST WEBER AVENUE, STOCKTON, CA 5)5 i-W (209) 4883420 _NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 19 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMIR INSTALL TIIE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITTLE,/CHAPTER 9-1110.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY IRl L/q HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESBIOR AIY7]J��I /��. �� ILA �l'I CITY, 1-6eA' E-�v pLOT MZE��" OWNER'S NAME//��•LI'"Ph 1 L[} L Lt i�I u en rA-- ADDRESS 'S//��¢h 1 P_--''II -PHONE 7C3/ �27(;,,5 Z//.— CONTRACTOR(=' F L E,J 1'(l[-!` �G'S/LJ 5 AODRESB �� \ R f�p-µA[Z Z (,�" Lq G Iz PHONE [`)� G z l•' SUB CONTRACTOn _ADDRE@6 UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION IIEPNRN1pdTION ❑ DESTIIlICT10N ❑ IND SEPTIC SYSTEM PERMITTED IF MRLJC SEWER 18 AVAILABLE WITHIN 200 FEET OF BI1ilDIN0.1 PEIC TSSTdI I 1 HOW MANY _j APPge. on e INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF gEDROOMS!_ �� NIMREI OF BHROYEn. CHARACTER OF SOIL-TO A DEPTH OF 33 FEET:_ ITT/SUMP SOIL CHARACTER: I'K ,.� WATER TABLE DEPTH T SFPC TANKIORFA@E TRAP �CAPACRV_ �e; NO.COMPATMENTB PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL/t1O Y FOUNDATION '5 y- PROPERTY LINF�(XJ 'P- UFT STATION eIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI -3 LEACNNU UNE IT—W.■LENGTH OF UNE@__ X 7 S Y DISTANCE TO NEAREST:WELL + FOVNDATIIN� PRppERTy UN[ 0+ FILTER SED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PMOMRry LME MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATION PROPERTY LINE SEEPAGE RTS 0 DEIN S F SIZE / YY NUMBER Z— DISTANCE TO NEAREST:WELL FOUNDATION_d ggPERTy LME �B O A BUNDS ❑WIDTH LENOTH� 7- EfTTI/ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE OIgPOML POMDe ❑WIDTH LENGTH ` DEPTH OISTANCE TO NEAREST:WELL FOUNDATION PnOPFRry UNE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AFRICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORLHNAMID AND @TATE LAWS,AND RULE, AND REGULATION@ OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CETIFN@ THE FOLLOWING:'ICETIFV THAT M THE PERFORMANCE OF THC WORK FOR WHIG THIS MnMIT IB ISSUED,1 BNALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COTRACTOR'@ HIRING On SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOVIING!•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 MALL EMPL /ERSON$SUBJECT TO WOIY(MAN'B COMMNC/TION LAWS OF CALIFORNIA. NT MUST CALL ZA NDUI6 IN ADVANCE FOR ALL PI[DLIIIISS INSP[CTIOMS. COMRET[DRAWING BELOW, SIGNED X C THIS // K •'� BATE:_ ROT PUN MRAW TO SCALE)SCALE •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE MKOMRTY, 1. Ot. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPORED OUTLINE OF iNfPgMnry.WITH DIMENSIONS AND NOTA DIRECTION. EXPANSION OF SEWAGE DISPOSAL SVSTEMg. 3. OIMFNSIOHED OUTLINES AND LOCATION OF ALL EXISTING AND PRKIM@FD 87RUM NIGER, B. LOCATION OF WELL@ WITHM RADIUS OF ONE HUNDRED FIPTY ET.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAL1K8. THE PROMPTLY OR ADJOINING PROPERTY. G l•1 - N • o �% x 12ti r�TAj 64 p.FEeTI 75 Kis-43-Las 53 ' lw�l r tI a-01 ae 3b^ AUG 1 - 1996 , ///2/— ipIV ��K1Ire.. qi ei , •:: FOR DEPARTMENT USE ONLY b APMIf.AT10N ACCEPTED BVD DATE: AREA: TANK,AT OR DAMP INSPECTION BV DATE I FINAL INSMCTION BV DATE p' I /6 176 ADDITIONAL COMMENTSwell 7'D begGA- /rn2/ kQy4>��, �(,�(r•�L �"D �G CIr HA:r�q.f�GG/ 7v iWef /&"C7' Sd 4-ef well '/D /t V U.CL( T' drd(i f'4�r ACCOUNT NO ONLY: IDI Lam(„ �,nyS Ir /VV F C 16 9G /�Y. .,2 i -( PE CODE FEE INTO AMOUNT REMITTED CHECK/CASH RECEIVED BY DATE an I PERMIT NUMBBK INVOIC[ 0 001 �3/� 3