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0NAPPLICATION FOR LIQUID WASTE PERMIT JOAQUIN COUNTY PUBLIC HEALT�VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmyM1tS in TrIPIkBtal APPLICATION IB IIERFRY MADE TO TILE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL TIM WOR(DESCRIBED. THIS APPLICATION IN MADE IN COMPLIANCE WITH BAN "AMIN COUNTY DEVELOME(11ff 11TITLEE'CHAP 8-1110.F./0/��/LMO THE TAMAARRDII OOFF BAN JOAMIIN COUNTY PUBUC HEALTH SMIS,EN/��V1Iro+N/M�ENTN IIE%A�ITN JOB ADDREBSNR ANI ` 1 `,) I \ �/nI ) V!" CRY • 1 `�l.Y j per/ '��L/(�f LOT SIZE V/ OWNED'9 NAME&,A2(!,-A I ,_ ' R %X26/S f ELW-egf• IDI^. L'ej IFILCONTRACTOR L ADDRESS JY7T s CAAPARdL Ci /�•� ) lC/ y� PRONE SUR CONTRACTOR ADDRESS LICA PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAMITION ❑ DEBTRIICTON INO SEPTIC SYSTEM PDMITIED IF PIBLIC SEWER IS AVAILABLE MINIM 200FEET OF BUILDING.' Me 1111111.11 1 NOW MANY ApPN..aen/ INSTALLATION WILL 1m VF: RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF(MNG UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMMOYEFA: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: RTMUMP SOR CHARACTER: WATER TABLE DEPTH SEPRC TARIMIMAIE TRAP ❑TYPE/MM CAPACITY NO.COMPARTMENTS PRO TREATMENT FLINT❑ DISTANCE TO NEAREST: WELL FOUNDATION PMPE.RTY NNE LFT IMATION❑ SIZE TYPE OF NMP BAND OIL SEPARATOR(ENCLOSED AYRTEMI LEACHING UNE ❑ NO.A MwaT"OF LINES DISTANCE TO NEARERT:WELL FOUNDATION PmPRTY UNE FILTER BED ❑WIDTH LENGTHS DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEARESTt WELL FOUNDATION RgPRTY UNE SEEPAGE PTB ❑nt"M mZE NUMBER DISTANCE TO NEAREBTI WELL FOUNDATION PoPRTY LINE BLIMPS ❑WIDTH UNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION FIROPRTV LINE DISPOSAL"NOR ❑WIDTH I-INUTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PEOPIT'LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED 71118 APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCOMAME WITH SAN JOAQUIN COUNTY ORDINANCER ANO STATE LAWS,AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY.HOME OWNER OIRLCENSED AGENT'S SKINATURE CERTIFIES TIM FOLLOWING:'I CERTIFY THAT NTNE PERFORMANCE OF TILE WOR(FORMRCM THIS PERMIT IB ISSUED,I SHALL MT EMPLOY ANY PERSON N SVC"A MANNER AS TO BECOME SUBJECT TO WORKMAN-8 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOFS"IBM OR SUB CONTRACTING SIONATUP CmYFMB THE FOLLOWNO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOEK FOR WHICH/TIIIB PBMR IS ISSUED.1 SNAIL EMPLOY PERSONS SUBJECT TO WOREMAN'S COMPENSATION"WWW OF CAUMMIIIAA.- T)NM APPLICANT MUST CALL 24 FOURS IN ADVANCE"IT ALL REGU9ED INIPCNONS. COMPLETE DRAWING BELOW. � Q] SIGNED x `LJf-1A.�� Lam\ / TITLE:_ LTLLA'VLL4 DATE: l 1 _� / POT PLAN mRAW TO SCALE)SCALE_ •le 1. NAMES OF INSFUS OR MADS NEAREST TO OR BOUNDING TIIE P RAPE . 4. LOCATION OF"OUSE SEWAGE DISPoBAL SYSTEM OR MIDPOSED 2. OUTLINE OF THE PROPERTY,MT"DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PMPRTY. Z) -:.._ SAFr rtlyd 11 ryPl r rrUrJ j'r. PULII.! ' ^,I.E61: -1 IVICES _:.. _. I`N IgUN61E r!I AL I Ir-TI FH I11VLS rya _. .._..__... ,_.._L. .:.... __._ ..:......:.... ..:...... . .... \� FOR pEPME USE ONLY /.� �� APPLICATION ACCFPTF.D BY_E U " "� Jap\ DATE /Vl `��)q�t"/L/)•�/� AREA. •/� ) TANK,N On BUMP INSPECTION BY DATE I / FINAL INSPECTION BY�eMpyt4riEIIiG. I TE l 2PG yY/ ADDITIONAL COMMENT 9: ACCOUNNNO ONLY: AID/ FACS PE CODE FEE Iwo AMOUNT IIEMIITED HECK/ BN RECEIVED BY DATE SN/PFINIIT NUM INVOICE/ 0115 itasa/ -� o Pub.Health Sew,-Enviro. 174 �—{r, (3/96) (f /E? ��'1 S�� _j 0,•'� ��23 I VB �� -to -42,