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A APPLICATI OR LIQUID WASTE PERMIT JO/1GUffi JNTY PUBLIC HEALTH SeRVICES 2l cmrrY-YUSLI si° �EWRONMENTAL HEALTH DIVISION 1DA1rt.1•� it A: t,11Egi bbh +W 'E;ER AVENUE, STOCKTON, CA 95202 A� ,, (209) a48 0 1C lQ NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED VV ICDmp1Eto In TrfpikatE) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMR TO CONSTRUCT MOAR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE W COMPUANCE WITH BAN J,RAW N COUNTY IN COMRAICTORM� DEVELOPMENT 'SER�9-1 DAMS DADODREeAefDG-SylOF G SAN .CO/ /•�/ HEALTH'TH�E�- l1CI - FMK HEALTH pVWN. • T B ADDR68qPWI ./Al - gz> CLOT 9 / -'OW 'S NAEQlWpq //lDN. i✓ A, RSO ;�X (D9OC j(0 PHONE Zs� RNE BUB CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORN: NEW INSTALLARO REPAWDDIiION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVMLA9LE WITHIN 200 FEET OF BUILDING.) FMC TESTI.)I 1 HOW MANY `N�' )� AppBBS FSn 8 INSTALLATION WILL SEINE: RESIDENCE El COMMERCIAL 11OTHER Ct � YI i_LI1:� NUMBER OF UVING UMTS: NUMBM OF BEDROOMS! NUMRM OF EMPLOYEES: CH TER OF SOIL TO A DEPTH OF O FEET PT/BUMP BOIL CHARACTER A L- /� WATM TABLE DERV -SO C TA EASE TRAP ❑TYPFiT.I —-Fo CAPACITY BOO I NO.COMPARTMEMB Y' WO TREATMENT PUNT❑ DISTANCE TO NEAREIST: WELLI6i'� 1L FOUNDATION ! F PIOPERfY LLNE o S UR STATION❑ SIZE TYPE P_BAND OIL SEPARATOR IENCLOBED BYBTEMI _ LEDMNO LINE >r-NO.a LENGTH OF LINE. PO E /IC DISTANCE TO NEAREST:wEu/fX9 1- FOUNDATION PROPERTY UNE -) FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED 13 WIDTH -1 LENOTH 1 OERN—_T�/s/e/x/DISTANCE TO NEAREST:WELL FOUNDATON PNOKFR LINE SEEPDE PTS E[BDEPIX t'Y�S , WE ell!/ NUMBER b 1V DISTANCE TO NEMEST:WELL FOUNOATMIN�PROPERTY UNE BUMPS /❑WIDTH LENGTH DEPTH s'� DISTANCE TO NEAREST:WELLFOUNDATION PROPRry UNE DISPOsa PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEARER:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY.HOME OV#4ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT INTHE PERFORMANCE OF THEWOM FORIANIOH THIS R IB 18ME?:1-WAL EMPLOY ANV PERSON SUCH A MANNER A8 TO BECOME SUBJECT TO WOMMAN'S COMPENSATION LAWS OF CALIFORNIA' COMMCTOR'S HIRING OR BUB ONT CTING SIQNAT4RECIES THE FOLLOMNO: I CERTIFY THAT IN THE PERFORMANCE OF THE VAR(FOR WHICH THIS PERMrt IS ISSUED.I WALL EMPLOY PERSONS SUBJECT TO WO MAN'S OM NO TlN LA8 OP\A FOIWIA.' CYILMUST CALL 24 HOLI1U IN ADVANCE FOR ALL REOU[RED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED THl£' ~ - DATE: U ROT PAPI PRAW TO SCALER SCALE_ 'to 1. NAMES OF STREETS OR MCAD OF TO OR SOUNDING THE PROPERTY. I. LOCATION OF HOUSE SEWAGE O(S SAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISP08K SYSTEMS. G. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WfFHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYS.AND WAU(S. THE PROPERTY OR DJOININO PROPERTY. PAYMENT _— '' ' AUG - 1998 1 n. , X J HEALTH SERVICES 1L/V� �F/ .... .... .... ENVIRONM L t1EA.LTH OIVISIGD _ -Y` g, 4� Y awt�A 4L1 UE Q 6 Sal. II a-say_,.�I FOR DEPAPTMENT USE ONLY ' APRKATION ACCEPTED BY DATE: TANK.RT OR SUMP INSPECTION 0Y DATE °y'�' INSPECTION /BY / DAPI -TE ADDITIONK COMMENTS:�1 -�-�� , �'~" • - - �V C�!/ I L Al 1T �� / S T� ACCOVNTNO ONLY: HIDA FACT ' DECODE FEE INFO AMOUNT REMI[TED CHEC CASH RECF,, BY DATE OR IPERMIT NUMBER 1NVOIOEB Pub.Health Sew.-Endro.174(3/96)