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APPLICA-ION FOR LIOUID WASTE PERMIT SAN JOAQUI14 COUNTY PUBLIC HEALTH SERVICES ENVIF'ONMENTAL HEALTH DIVISION _ 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNOARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBmpIEtE in T*lican) APPLICATION IS HEREBY MADE TO THE BAN JOAOUIN COUNTY FORA PERMN TC CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMMANCE WITH SAN IDAG VIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF GAN JOAGVIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. Joe AoorE6sroR AP+I � �52/f.- LlJ Y�L�R,( � crtY �Ci f�D`I Lor SIZE OWNER'S NAME // r../O• ADORE Sv C` MONE OR /)� p CONTRACT (�.�fel /I /(fl�� ADDRESS / Z�v/c'i (' /�✓G✓ C�it}'O I F y,/ PIONE�� 6VB COMPACTOR AODPE6l LIC ✓�I fNONF TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AODITION DEs TRUCTTON❑ INO 6EMIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING-1 ►FRC TFITISI I I HOW MANY _ Apptlutlon/ INSTALLATION WILL SEINE: RESIDENCE COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UMTS:_NUMDOI OF SEDPOOMS:�_NURSER Of fA1ROYEF3: C' CHARACTER OF SOIL TO A DEPTH OF J FEET: PIT/SUMP 601;CHARACTER: WATER TABLE DEPTH SEPTIC TANK/DREASE TMP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PALO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL^Ze)d�" FOUNDATION .- lI RFIOPERTY UNE�G� LIFT STATION❑ SIZE TYPE OF PUMP p' SANG OIL SEPARATOR(ENCLOSED SYSTEM( 1-c...LIME I NO.S IENOTH Of ONES /"6�J t _DISTANCE TO NEMEST:WELL / FOUNDATION-!L•Q PROPERTY UNE _ FILTER SED ❑WIDTH LENGTH DEPT/(__DISTANCE TO NEAREST:WELL FOUNDATION PKOPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH_ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE FITS ❑DEPTH WZE NUMBER__DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH__DISTANCE TO NEAREST:WELL FOUNDATION MOPEFITY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH__DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APMCATION AND THAT THE WO K WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AG EM'S SIGNATURE CERTIFIED THE FOLLOWING:MI CERTIFYTHAT IN THE PERFORMANCE OF TETE WOFK FOR WHICH THIS PERMIT IR ISSULL ED,1 SHANOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S HIRING OR SUSLo WRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PETEORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CA-L 24 NOGFIS IN ADVANCE FOR ALLRE0U1RED I N SPECTIONS. COMPLETE DRAWING SELOW, C { ��iJ'�iYIY�j DATE: SIGNED% TILE:-��V ��(l�6 ` POT RAN MRAW TO`R'" SCALE_ 1.NAMES OF DTRFETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. Ia4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIOPOBED 2.OUTLINE OF THE PigPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. JRO . DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION Of WELLD WITHIN RADIUS OF ONE HUNDRED TUFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. . _ .... l . . ._fry ..................... . � I P79/Z j, �l1 .....4........ ,,�f,,>� E k/.t Z2C _ e..... ..a. ,..., -. i ...;.....:......:,........ ... .............:........... ......................... . . ...... . .<.. . . . . . . . . . . : ..::::::::.:... ,.... ..° E1UG 1 199 ............>..... ...................:1........... . .. `. p.... AQ IJ W NCE .... ..i.. !. .. , SAN JO PUBLIC HEAT H-SE g.. ENVIRONMENT AL EiALTH DIVISI ti .:..... No TOR DEPARTMENT USE ONLY r AF'F'IXATION ACCEPTED BV C �� 1 DATE: I C REA: 7- TANK.RT OR BUMP INSPECTION BY GATE / / FINAL INSPECTION BY DATE I ADDITIONAL COMMENTS: -� AC COUNTING ONLY: NDP FACI PE CODE FEE INTO AMOUNT RUAIITEO ITEC IC A611 RE'—BY DATE AR I F'ENM11T NUMBER INVOICE I Pub.Health Sew,-Enviro.174(3196)