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"- A• FOR LIQUID WASTE PERMIT SAN JOAQ'1„r1 COUNTY PUBLIC H 3 EALTH SERVICE'S ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 fi10N•REFi1MDABtE PERlYf{T EXPIRES f YEAR FROM DATE ISSUED (Complete in TTip{ieate) I'UCATIOH IS HEREBY MADE TO THE SAN.JOAOUlN COUNTY FOR q PERMITANDIOA +�► NSTALL THE WOUIN COUNTY DEVELOPMENT"TLF,CTIAPTER 8-1110.3 AND THE STANDARD OF SAN JOAQUIN(COUNTY PUBLIC WORK EALTH SERVICES.iENVIRONMENTAI EDESCMBED. THIS APPUCATION IS ALTHNDIVISIONANCE WITH BAN wp I ADDRE88/OR APNI)F,�, SIJ �'/7! 2 �. ! �, 94 NER'S"AM' c)kvk 2-Lut; `+1� ( h CITY `Kl�`-`7 'y LOT SIZ -t .� I - �.� ADORES�'t� Cl �, e-'J L4-rte PHONE RRACTOR r[/ ]� Ly.,C ADORER C i�I j (� _ LK:I PHONE CONTRACTOR q ADDRESS UCIPHONE F OF SEPTIC WORK: NEW INSTALLATION ❑ - - .Y REPAIRIADdTION DESTRUCTION❑ SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILINNG.I YERC TIOT1U 1 1 HOW MANY ALLATION WILL Sl RVE: RESIDENCE* COMMERCIAL ❑ - EAppilmdon I - �;M OTHER❑ , IER OF LING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: UICTER OF SOIL TO A DEPTH OF 3 PTT/SUMP SOIL CHARACTER; f� WATER TABLE BEAT C TANK/GREASE TRAP ❑TYPffMFG I CAPACITY NO.COMPARTMENTS TREATMENT PLANT❑ INSTANCE 70 NEAREST; WELL FOUNDATION PROPERTY UNE - SAND 0 +�81�ZE TYPE OF PUMP { SAND OIL SEPARATOR{ENCLOSED SYSTEM) INQ LINE, - ,NO.A LENGTH OF LINES O /•%CA-2r INSTANCE TO NEAREST;WELL C3 ) ,�. '�FOUNDATION�.S pgpP'Ep7y LINE I BED ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION LENGTH PROPERTY LINE DL'b ❑WIDTH DEPTH DISTANCE TO �j NEAREST.,WELL FOUNDATION PROPERTY LINE OE PTS jo DEPTH•SSI2E�`NUMBER. R3, DISTANCE TO NEAREST:WELL I r I / - I !� f❑`WIDTH FOUNDATION �� PROPERTY LINE` LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE- IAL PONOS D WIDTH LENGTH DEPTH - DISTANCE TO NEAREST:WELL Y� FOUNDATION PROPERTY LINE IY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORdNAhICEB AND STATE LAWS,AND RULES ;GULATIONB OF THE SAN JOA WIN C06fNTY,NAME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.•I CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH iRMIT IS ISSUED. SHALL NOT PLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION IAWe OF CALIFORNIA.' CONTRACTOR'S HIRING C I SKI TUBE No 8 THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 198UED,1 SHALL EMPLOY PERSONS SUBJECT TO AN'B O 9 10OR lJW CALIFORNIA- THE T MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. r i X �� / �l C r TFTLE: '�I DATE: PLOT PLAHIDRAW TO SCALE{SCALE •Eer IES OF STREETS 0 AIDS NEAREST TO OR BOUNDING THE PROPERTY, - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED UNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, �• ENSIOtIED OUTLINES AND LACATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr.ON /INNG COVERED AREAE SUCH AS PATIOS DRIVEWAYS AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ........ ......... EY - -- ..:.. I C .. z .. y _ '' ...max .. .... ...: �,> ......� rJ. :.. : r _;..... f ........ ............ ......... ..:....., ............... -......:.... ...... ......:-�....:.....,:...,. .. . � r FOR DEPARTMENT USE ONLY �J `I ^? ( = ON ACCEPTED BY � v DATE: � AYEA: _ OR SIUMP,INSPECTIOH BYE DATEFINAL INSPEC710h BY - C/ �DATEr .�f" WL COMMENTS: °h LATINO ONLY: AIDS FAC{ - 5 FE i� FEE INFO AMOUNT RENNITEO CIBC /CASH RECEIVED BY DA7 SR IPERMIT NUMBER INVOICE 0 !alth Serv.-Errviro.174(3/96) ri i