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/ APPLICATION FOR LIOUID WASTE PERMIT / MAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N, SAN JOAQUIN ST., STOCKTON, CA 96201-0388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CNyNu M TrIPIiF{a) APLCATION 18 HEREBY MADE TO THE BAN"ADM COUNTI'FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE MIST DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE MEN SAN JOAWIN COUNTY DEVELOPMENT TITFITILE(,�CHAPfOI 8-11110.3 AND THE �STA BGARD11 OFF SAN"AWN COUNTY PUBLIC HEALTH SERVICES,E�N/NRONMEFM•�AL HEALTH DIVISION. JOB ADDREBBroR1/p1}ARM� # 3 l -I �L In-Z 1� YVNCA VN 11„�y& ^F�Cm CCLV UO\A"\ �yLOT SIZE OWNER'S NAME VYN';L1'("000%1CA Swt,yE ypy\gppRE58 (,r'V 1C /�'��II 1VLAC�L PHONEI�/•'v> CONTMCTOR ()CLV V t b L\ /SU11/L, ADDRESS 7 OOO I/`/I �I, I SGN L•'h'L.11 LIDf /WS1 i MmNE1� _ 9b0 1 SUB CONTRACTOR ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION tK REPAIRIAODITION ❑ DEJTTR.U.N ❑ IND SEPTI:SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE VWTHIN 200 FEET OF BUILDING.I MRC TFATW I 1 HOW MANY APdhneon INSTALLATION WILL SANE: RESIDENCE❑ COMMERCIAL SOyy5I L OTHER❑ NURSING OF LMNO UINt{: MI m DF{EOROOM{: NIIBMFIL OF 6AROYFSS: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: .5=O(•'IG� / PITIIUMP SOIL CHARACTER: WATER TASTE DEPTH �+ _ SEPTIC TMOUGREASE TRAP IkTYPE m GV CAPACRV 0 S .F .COMPARTMENTS L. U MG TREATMENT RANT❑ DISTANCE TO NEAREST: WELL to L FOUNDATM /b L FROPERTY UNE -- LIFT STATION❑ SIZE TYPE OF PytAF SAND OIL SEPARATOR(ENCLOSED SYSTEMS LEACHING ULD) L�O(7L NE I'S NO.B LENGTH OF LINES LIO,(4jdW4LL16 STANCE TO NEAREST: 0 c FOUNDATION PROPERTY UNE L FILTER am 13 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDOt 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SHAM RTS ❑GEFTN SRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PIOMNTY LINE SUMPS 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DMPO{AL PONOS ❑WIDEN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE -F•+ I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES / AND REGULATIONS OF THE SAN"AMIN COUNTY.HOPI OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTNAT IN THE PERFORMANCE OF THE MW FORMUCH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB CONTRACTING rITA URE CERTIFlES THE FOLLOWMO:'I CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM AT N LAWS OF CALIFOIWIA,,f O,/(\APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR A11.]SEQUINED INSPECTIONS. COMPLETE DRAWING MEOW... SIGNED% �� _1 TRIf: V l� V DATE: PLOT RAN(DRAW TO SCALE)SCALE '1P _ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMISED 2. OUTLINE OF THE PROPERTY,WITH DIMENBIONO AND NORTH DIRECTION. "PA G ON OF SEWAGE DISPOSAL SYSTEMS �1 _ 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS„DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 5 IIr I I I I Orr I 1 I . ,1 At 9 i tR (daft 2 81991' FOR DEPARTMENT USE ONLYJVI OiMF�T / HF.AIIIi GLV !1r AFRICATON ACCEPTED.BY /J._� ,._ DATE: AREA, " 1 AIM,RT ORS UMP INSPFCTLIN� ��I� `� �� InI /L� DATE ,(ILe�I I�T,�,,/FINAL INoSP^E�C,TIOONNBY L I..DATE 1 7 ADDITIONAL COMMENTS: `PV F 'IyLi :k/1 /IRtRA4�4 �•E '1I�•� � — ��'T'V"" "oom '�'F"F'" I41M IY' O\Y"cc (�F"L 0-404 ^T., Wv-^' OKd GQ V a tO fZ.AOIC --X.' J-f- L,ItN{ '� an 4—IkllI-\ yr- ',itk tv ACCOUNRNO ONLY: AUDI FALL 02 N2 If—' PE CODE FEEINFO I AMOUNTREMITTEO CHECKIICA6H RECENEDBYINB DATE M I PERMIT NDBI— ICE'IICE♦ y I So1 JLO. co 1 1`10 -3a8