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App ' I FOR LIQUID NIAETE PERMIT IN COUNTY PUBLIC HEALTH SERVICES LC,L?�pB�eV t IRONMENTAL HEALTH DIVISION R .pDX 3SB,. N.SAN JOAQUIN ST; STOCKTON,CA 95201.0388 `tel tel:• �•.;,- 3r `��b (202)""•3420 MDRFREFUEIOABIE PERMIT EXPIRES i YEAR FROM DATE 18YDED in Trpfiints) a APPLICATION IB HG E KY TO THE SAN JOAaM CODNfY FOR A PERMIT TO CONBTRUCT AND/OR INSTALL THE WORK DESCRIBED.TNS APPLICATION IS MADE N COMPUANCE W"BAN JOAOLRN COUNTY DLVELOPWNT TIRE CHAAPM 0.1110.3 AND THE STANDARDS OF BAN JoAOUN COUNTY PUBLIC HEALTH SERVICES,D&MION kNINTAL HEALTH DNNIION. JOB ADDRESS/OP APNI_ V` 1�� -CITE` E �� p�LOT -Es ' OWNER'S CONTTMCTON ��._J�A-rT C_ A001E6S�s�4�'C7 �4Fac'L�'tt1l� ��v� UCS �5"7.�1 PNONE_3�Og' ��.Y3 SUB CONTRACTOR C' ADDRESS UCS _PHONE TVP/OF SEPr1C WORK: NEW NSTALLATION❑ � MYTRUCTON❑ DNO SEPTIC SYSTEM PERMITTED IF PUBLN=SFINIER IS AVAL ANE VWTIM 200 FEET OF BUKDNG-) PK 7RBT►1 I 1 NOW MANY APPB.dee INSTALLATION WILL SERVE: RESIDENCE B COMMERCIAL 17 OTHER O NLFASM OF UVING UNITS: / N17 om Of M®IIOORM:__3 NUMBER OF MPLOYM: CHARACTER OF BOt TO A DEFrH OF O FEET: C,2,ck,(n IRTAIAM SOL CHARACTER: - WATER TAKE OWER -Cb" SEPTIC TANK/OEASK TRAP ❑TYLE MFF CAPACITY M.COBMAFTB®ITS PKO TREATMENT RANT❑ dSTANCE TO NBAIMT: WELL _ FOUNDATION PIIOP9lrY UIE IIT STATION❑ SUE TYPE OF PUMP SN®OIL SEPARATOR(ENCLOSED SYSTEMI LEwOHINO LINE ❑ NO,S"NOT"OF UNEB DISTANCE TO WARIEST:WELL FOUNDATION PIOPERrY LINE FILTER Am ❑WROTH LENGTH__DEPrH INSTANM TO NEAIEBT:WILLP'7UMOATION PROPERTY UNE MOUND® ❑WIDTH LHFCI-M DEPTH DISTANCE TO/EAREw WELL ROURDATRON PIOPBRY UNE SE PAIGE MS 13 DEPTH B1tE NNit ERBFAMII TO IEAIESr VAIN POUNDAT.ON PRIDPE ITY LLE + SWPS WIOTN ' t LENGTH e-IU • DEPTH$_ONTANCE TO NEAREST:W8L_*20_L_FOUNDATION 1,,V PROPERTY LINE DISPOSAL PONOS ❑WIDTH UMTN DEPTH OWA14CE TO NEAREST:WELT FOUNDATION.PROPERTY L04 - I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORN WILL BE DONE IN ACCORDANCE WITH IAN JOAOINN COUNTY OIWINANCES AND STATE LAWS,AND RILES ANOPEOULATONSOFTHESAN JOAOUN COUNTY.HOME OM"OR LICENSED AOElT'S SIGNATURE CERTIFIES THE F2PADYMM:'I CERfIPYTHAT N W THE PERFORMANCE Of THE ORK PORYMICH Q THIS POWIT if ISSUED.18HALL NOT EMPLOY ANY PERSON W SUCH A MANNER"TO BECOME SuWIquT TO WOIK/JAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTDTS HIPOSS OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT N ISOM.1 04AU EMPLOY PERSONS BUSJECT TO WOMMAN'S COMPEN TION LAWS OF C�FRIA,' THE APPLICANT NWT CALL N HOUPS N ADVANCE PON ALL IIEQMRW MWVWTONB.COMPLETE DRAWING BELOW, q IPM S16IID I �_ VJ TITLE: r eiZ- 5 ATE ROT RAN IORAW TO SCALE)SCALE. 'W 1NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I.LOCATION OF HOUSE SEWAGE 01WOBAL BYSTOA OR PROPOSED 2.. OUTLINE Of THE PROPERTY,WITH DIMENSIONS AND HOKM DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTOM- O. DIMENSIONED OUTLINES AND LOCATION Of ALL EANTNG MND P OPOSED STRUCTURCS, S.LOCATION OF WELLS WTHN RADIUS OP OW/ *PMD FIFTY FT.ON n INCLUDING COVERED MEAS SUCH AS PATIOS,OISYMMYD,AND WALK 8- THE PROPERTY OR ADJOMSLR PFAIPWT v.......:. - s v ....... ...... 1 _ ._,_.. o I :......................... ... .... ' ... : . �...... .: ................ z- ....... ...... A � TEB 1 IRAN=UFGIiiu...i.;,.:- PUBLIC,HEALT!'I SERVICE~ I . .°. . . ...: . ... . . .. .:..... . ..°.:.IuNIRDNtdEN?ACara�T�:OIU�SKn:...�_. •. .... P� FOR DEPAR MINT SME ONLY APPLICATION ACCEPTED BY C ITA GATE: AREA: _Zl � TANK.PT OR SUMP MSPECTION BY DATE f ! fYUI INSPECT—by 91&1 DATE R, tC 1 17 1 ADDITIONAL CONIMENTS: (t�= �)"'( _�GP�1��% [](,A�`'LC - F •V \ �fN� .aJ(fyT PL pef s/'_j_ 'LTA ACCOINTINO ONLY: AUDI TACO M CODE FEE INFO AMOUNT RGHTTED 484 c"" RECEIVED SY DATE SR I MMT SMMmF1 NfY010EI 190 O y l V Al.?