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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC-wi-t-IRI TFipinnl APPLICATION 10 HERESY MAIN:TO THE BAN JOAOUIN COUNTY FOR A PFPMIT TO CONSTRUCT AND/OR INSTALL THE KORO DESCRIBED. TRIO APPUCATON M MADE IN COMPLIANCE VATH SAN JOAOUN COVNIT DEVFLORIENT TITLE.C14A(P�T'ER 9.1111110.3 AND THE SI ANOARDSCO_F SAN JOAQUINFC"O�UN,,TTY PUBLLIC,HEALTH SMACES,ENVMHMENTN HEALTH OMeDN. JOS ALID1ESeAR NTIF y. OI{,j 1 ]11—30 �(InjoyY-,7ac F/I/K.O4*W/ilft"R)CRT L'JT BIZF�Qf�L oMNER'B NAME AV-1 �yA.LA��IU IlCX4 ICLA AOOEESR J^�OJO O!1��Q}C.L.D�IFV.CI1 NOM C'►� -PHONE-- CONTRACTOR a,a.- �P /�n.PrTr!�.�Y/. �� ADDI1E6f f71aLI},mow,..-Cal--,St-,, .7)P- ,Ca/O'/\ (Wd; LIC. PHONE^�� /� SVS CONTRACTOR \ L1�YUGf.L•��I'TS3JC- IIIOR[BB ISN CiUY14✓I WV 1 �I' Zl -1I�LC/ "NONF367`5 7() TYPE OF 00 T WORK: NEW NSTALLATNLN❑ RFPARVADOTDOM ❑ DESTRUCTION❑ I NO MPFC SYSTEM PE10.1RTED IF PUBLIC BEVYTR IS AVAILABLE WITHIN 200 FEET OF SUH-I NO.I PB1C TBSi N11 I writ/MANN'_1 AfMeM1eR f_ NSTALLATION WILL SEWS: REMMEICC❑ COSWLICIAL❑ OTHER❑ "UNIMII OF LIVING UMTS: REAPER OF BEDROOMS NR M OF MPLOYm: CHARACTER OF BOO.TO A DEPTH OF 3 FEET:_ PIT MUM P SOIL CHARACTER: WATER TABLE DEPTIL_ SVTIC TANKIOREASE TRAP ❑TYPE/AE.A -_CAPACITY _HO.COMPARTSAFNTS PKO inFATMENT PLANT❑ DISTANCE TO NEAR IT: WEt-L FOUNDATION ROPERTY UNE LFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR ENCLOSEO BYSTEMI LEAMNO LIVE ❑ NO.S LENGTH OF LINES_ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER SED ❑WWIH LENGTH_ DEPTH DISTANCE TO NEAREST:WELLFOUI/DATON PROPERTY UNE MOUNDED ❑WIDTH LENGTHDEPTH PRANCE TO NEAESTf WELL FCUNOATION PROPERTY LME SRPAOE RTS ❑DEPTH BQE _M7M8ER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LONE / SLUM ❑WROTH LENGTH —DFPTH DISTANCE TO NEAREST:WEU._—FOUNDATION PROPERTY UNE / DISM&M.PONDS ❑VADT" LENGTH DEPTH DISTANCE TO NEAREST:WELL—_—FOUNDATION PROPERTY LIVE i HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THA',THE WORK VALL RE DONE IN ACCORDANCE YMN SAN JOAOUN COUNTY ORDNANCES AND STATE LAWS,Am RULES AND fEOULATONS OF THE SAN JOAONN COUNTY.HOME ORMNER OR LICGIWo AOENT'S SIGNATURE CERTTHES ENE Fo LLv~l"cERTIFYTHAT IN M PERFORMANCE OF THE WORK FOR WHWH TWO PEWFT It MSUED,1 SHALL NOT FMPLOV ANY PERSON N SUCH A MMHER M TO BECOME SUBJECT TO WOIKRANI*COMPENSATION LAMS OF CALFORESA.• CONTRACTOR'S t�S1IG OR / SUSCONTRACTNG SIGNATURE CETRSIEB THE FOLLOYVM:•1 CERTIFY THAT IN TtE PERFORMANCE FORMCE Of TNF YMM FOA WHICH THIS PERMIT M ISSUED.1 SHALL EMPLOY PERSONS fVB.JECT TO (y/ WOMMAY/S�COMAEN ION LAWS OF AWSOFF CALNORMA-- "A APPLICANT MUST CALL 24 14OURS IN ADVANCE FOFI Ai RrSOM"'B"WGMTONS,COMPLETE DRAWING BELOW SIGNED% l'N LL E-1(/V �� IRLE f�R71�wrS� DATE: S_I f��^••�/'L/� PLOT PJVI IDMW TO SCALER KALE ( I WLL'1 •te_ 5s3 �a 1.N rAWg OF STREETS 09 RDAOS NEAREST TO OR SOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSALSYSTEM OP RIDPOS® 2.OVtIIE OF THE PROPERTY,WOH NMENSIOfRS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEAS. 2. DOWNS10NED OVELNES A D LOCATION OF ALL E%MTING AS]PROPOSED STRPCTUMS. S.LOCATION OF WELLS VMHN RADIUS OF ONE HUNORED FIFTY R.ON NL7LRONG COVERED MEAS SUCH N PATCH,DFMWAYS.AND WALKS. — M PROPERTY OR ADJONWOO PROPERTY-55 — - - I/ 1 o i xsx I Z 1 m I MAY Z s2mI Acay�p L) b ,:•::: :: :::.: SA4 MENTO \ _ ROAD --- - FGR O[PM TIRR[NT USE ONLY Ap,,MATON ACCEPTED B� _ DATE' E+-i a/ 26c�n .' ZT/(y/1 TALK,M OR SUMP IN81, 10 DATE I I FINAL INSPER1001 - � I 'ATC L -51 ADDIEOHAL COMMFM (/ ACCOINTRW ONLY: AOI FACE PE CODE EFL INeFO AMOUNT RDISITER SLC FAS" Fw.OVED BY DATE NUMB, Pub He61tI SON-Ewm 174(3198) l