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tIIIM I� - APPLICATION FOR LIQUID WASTE PERMIT •"" 3 30 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JUN 2 9 2000 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 448 N. SAN JOA IN ST., STOCKTON, CA 952010388 ENVIRONMENT HEALTHL,A \ps) 4e a4zD PERMIT/SERVICES I q,700 NON-REFUNDABLE PERMIT EX IRES 1 YEAR FROM DATE ISSUED (C6mplou in Triplicate) AFFMATION IB HEREBY MADE TO THE EAR JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DES KISED. THIS APFEIOATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER.9-1/11 O.3 ANO TH'E�/TANDAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIOES.ENVIRONMENTAL HEALTH DAVISON. JOS ADDRESS/OA APNF R o ,4 ` -'� ��'J /I CT' y1 LOT SIZE PL Ae- OWNER'S NAME.(_/QNJ"-- •V ADDRESS-LY—Ton (A� ,,W V I(�1 �1�2T�' HONE - rN CONTRACTOR -v / CCFC-F a ADDRESS •]•I I')TC , 39-3yoL> SVB CO OR 7' ADORESSI\ ,0. ` UCI RHONE TYPE OF Sm;Tm WORK: NEW INSTALLATIOR ❑ REPAINADDITION65�7 DESTRUCTION [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILUING i PgIC TESTI.)I MOW MARY APPF>tbn/ INFTAl1ATION WILL BONE: RESIDENCE❑ COMMERCIAL L>,y/ OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF S GROOMS: NUMBER OF EMPLOYRSE / CHARACTER Of 601E TO A DEPTH OF]FEETr./P./ I RT/SUMP SOIL CHARACTER: WATER TA[NE DEPTH M2 •c.0 L, SEPTIC TARDOREASE TRAP ❑EYF'ErMFI CAPACITY Na.COMPAITTMENTB WO TREATAMFNT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION ITgPERTY LINE UFi STATION❑ SIZE. TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEM) LEACHING ONE Y-Y/NO�B'LENOT�H O,LINES �� T/.C.L 11J L1�} I D agANCE TO NEAREST:WELL farm FOUNOATnN 9 0 FIgPERTY LINE �G FILTER EEO ❑MOTH LTNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPENO,UNE MOUNDED ❑WIDTM UNGTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRORRTY UNE SFEPAOF RTF ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PRDPERTY L A, SUMPS 11 MOTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION iKOFENTY ONE DULMSAL PONDS ❑WDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION RgPENTY ONE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WOFK WILL BE DONE IN ACCOMANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORMENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE RPROWM E OF THE WORK FORWHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWI! -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS FERMI IB ISSUED.I SHALL EMPLOY RRWNS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF/CC AAALLIIFF�ORNW- 1 AMECANT MUST CALL U HOW IN ADVANCE MK ALL INFPB COMPLETE DflAONO BELOW. O O SHINED X `� ' L'41-t �f ROT RAN)DRAW TO SCALE)SCALE -He 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. a. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR RDRg9EO Z. OU IU E OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTDHES AND LOCATION OF ALL EXISTING AND ETDMI,I STRUCTURES, 6. LOCATION OF WELLS NTTHIN RADIUS OF ONE HUNDRED FIFTY A.ON HNCLUNNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAlKR THE RVIKFETY OR ADJOINING PRDRgTY. I - + _ I rrK-Trr--r— « ......... .... ...__. ------ a e Fes" ........... .......... a� •r«- pro/..•.a a., � r •vv* 0 ._T ` 1 t z7 RECEIVE t We 0 2000 _t t __ . f` t � •HT.•ryN ,RUN 3 � j �..r.;^^'.•., a m.,.o.G ,w.. a SAN i0p, N GOUNIv �.. rl.,p•laF PUB RASION PSM RIC Ht AETIi SERNDE" I � _► n <fN•IMfIR.or ENVIRONIAENtAI HEAETND , Y./H W.. -- , «. • t -- ooaa0 - -" �RH< OWENS—BROCKWAY TRACY y — PLANT qq -....H N..I E SM',T1MExII USE ON APPUCATIDN ACCEPTED BV W/��/ A'IE: AREA. a,��....,`� �1 1 TANK,PR ON BUMP INSPECTION BY - •' DATE_ -INSPECTION BY DATE=/ a'CJ ADDITIONAL COMMENTS: 7- ��-zpco p - I „ P I It p 9 i i y 7Dy y 3o.M, n FSO 1 "hF J ACCOUNTING ONLY: AHDA FACE PE CODE FEE Iwo AMOUNT REMITTED CHECK" ASH RECOVED BY DATE M/ EI INVOICE F -75 I-2 .2zy77/ 30 o'D 73 (O I Ivo s•(LGO?S ,L lIZr/o� 1 'D( ...�•E.c c-t1•W�-�-e..�Q-p� n/A6.v -1e�w�a we�9s - �LVL.t I(�eA�j n-M'�� o }o�O R ywu u 1{5 w( ,f,� (oo3i (y r }F E cfz l s utT LN,-. Ov" �LQ/J� I I �t w q Z, VLPno L wex(� wok'. pe rvI p + I r5pti ii n-- Y -m*ulz a j &"It-