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t APPLICATION FOR LIQUID WASTE PERMIT D,U05D5 <br /> WkN JOAQUIN COUNTY PUBLIC HEALTH SwiVICES <br /> ENVIRONMENTAL.HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complrte in Triplints) <br /> APPLICATION IB HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY bEVELOPMENT TITLE.CH ER�8.11 10,3 AND THE=et <br /> UNITY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION.JOB ADDRESSIOR APHN �-` CITY 1' L-OT$IZe!gL ' <br /> OWNER'S NAME "�f1- �� �L ADDRESS PHONE N '. <br /> CONTRACTOR ! ""IZ 1!J/✓ s��_�Y�ADDRESS / L�/`���.�/ &K_L1C/ P ONE <br /> SUBCONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPALRUADDITIO DESTRUCT_LOSS❑ <br /> (No SEPTIC SYSTEM PERMITTED IF PUSUC SEWER IS.AVAILABLE WITHIN 200 FEET OF UILDING.i PEISC TEST{u)[ t HOW MANY <br /> AppSeatlon/ <br /> INSTALLATION WILL BENE: <br /> RESIDENCE D COMMEFICIAC L.]"�" OTHER 13 <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: - <br /> CHARACTER OF SOIL TO A DEPTH OF 3 �liMFITASUMP SOIL CHARACT Z A R TABLE DEPTH /7 T <br /> SEPTIC TANK)OREASE TRAP ❑1'YPE/MFO CAPACITY NO.COMPARrMENTs <br /> PKO TREATMENT PLANT❑ 04STANDE TO NEAREST: WELLFOUNDATION PROPERTY LINE <br /> LIFT STATION❑rv"DTH <br /> SIIZE TYPE OF PUMP ��"�,'L-/ p SAND OIL SEPARATOR(ENCLOSED SYSTEM] I J <br /> LEACHING LINE NO.a LENGTH OF LINES,A6d4 A_r-. c•:r �DISTANCE TO NEAREST:WELL�.SKI <br /> a 1�10NDATN/!PROPERTY LINE SO --� <br /> FILTER REP LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED [3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SEEPAGE ATR ❑DEPTH SIZE NUMBER INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SURPsIDTH-�_LENOTH1�0! DEPTH DISTANCE TO NEAREST:WELI/ _-FOUNDATION LD I PROPERTY LINEy �r <br /> DISPOSAL PONOS 13 WTOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE RK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> ANDREQUnT1,111BAN AGUMCOUNTY.140MEOWNERORLICENS ENT'BBIONATUACERTIFIESTHEFOLLOWING:'ICERTIFYTHATINTHEPEIFORMANCEOFTHE%WAKFORWHICH <br /> TH18 R: NS Hi EMPLO - PERSON M BUCH A M E AB TO BECOME BUBJECTTO WORiCMAN'B COMPENSATION LAWS OP CALIFORNIA.' CONTMCTOR'flHIPoNOOR <br /> SUB-C NTRE CE F T E FO OWING:'1 CERTIFY AT 1N HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WO WS C RNLA• THE APPLI HOURS 1N ADVANCE FOR ALL REQUITED INSPECTIONS. COMPLETE DRAWING SEIAW. <br /> 81G X --DATE: <br /> TITLE: <br /> k <br /> PLOT PLAN IDgAW To BCAL.E1 SCALE •to <br /> 1. NAMES OF STREETS OR ROADS NEARE OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DI8POSAL SYSTEMS. <br /> 3, DIMENSIONED'OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> - INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPS OR ADJOINING R10PERTY. <br />]III <br /> .... _ �� ... . ...'.... <br /> .. <br /> r <br /> .... <br /> : <br /> ............ .... ..... 4"" �-9 ...... ........... ... <br /> . . o <br /> . <br /> : . <br /> FA <br /> r4G J �t�s <br /> AUG <br /> 1� 8 r ...S � <br /> SAN JOAGUiN CUIJNY't <br /> . � - <br /> ` gNV1R4NMENT.At H AL111471Vi9COI� <br /> .,., <br /> 4 � <br /> 4 <br /> -FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE: AREA:, /J <br /> TANK,PIT.OR SUMP INSPECTION BY DATE FINAL INSPECTION BY 60ATE <br /> ADDITIONAL COMMENTS: <br /> I <br /> ACCOVNUNQ ONLY: NIDI FACT <br /> PE CODE FEE INFO AMOUNT RM ITED HEC UCASH RECEIVED RY DATE an U PERMIT NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.174(3196) <br /> r <br />