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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON REFUNDADEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBRpitld In TrlplkBbl RK DESCRIBED. THIS _ <br /> ANDMR <br /> NSTAU THE <br /> JOAWAPPLICAN COUNTY DEVELOPMENT TRIS. N JOA RUIN OU T AND THE AMIISTANDAROB OF SANTJO RUIN ILOUNTV P1BLWIC HEALTH SERVICE,ENVIRDNMENTAL HEALTH DIVISION.CATION 19 MAE IN WITH SAN <br /> �I:N� (7 LOT SIZE�A�' <br /> JOB ADDR6SPOR APNF <br /> 7 \ lC7 \/J L(i R10NE�Z LI <br /> OWNER'S NAME �� I `�`v <^7 Y� ADDRESS lKI PHONE <br /> CONTRACTOR O\E^, C\I t \4— ADDRESS <br /> UCS PHONE <br /> ADORE69 <br /> SUB CONTRACT00. <br /> REpIURIAOdTION ❑ O"TRUCTON 13TYPE OF SEPTIC WORK: NEW INSTALLATION MANY ^ '\ <br /> FERC TESTIER 1 I NOW 1 v <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC S.EEW/ER�I6 AVAILABLE WITHIN ZOO FEET OF BUILDING.) AFFSaStlan l \, <br /> INSTALLATIONEI <br /> WILL SNE: RESIDENCE IJ COMMERCIAL ❑ JJ OTHER ❑ � <br /> NUMBER OF LUNG UMTS: I NUMBER OF SEDROOMSHUMBRR OF EMPOYEFA: V I <br /> (� WATER TABLE DEPTH <br /> CHARACTER OF SOIL TO A DEPTH Of J FjET: \ PTUSUMP 601E CHARACTER' O Gp Y NO.COMPARTMENTS <br /> SEPTIC <br /> I <br /> SEIC TANN/ORFASE TRAM TYPE/MFO ( CR-k lE ACRY PROPERTY UNE <br /> RI TREATMENT SLANT❑ DISTANCE TO NEAAEAT: LL L FOUNDATION 9 <br /> UFT SUTON❑ SIZE 1YPE OF PIMP SANG OIL SEPARATOR ENCLOSED SYSTEM) <br /> _ / PROPRTY LINE n C� <br /> I [� <br /> NO.B LENGTH <br /> X a DISTANCE TO NEAREST:WELL�QO <br /> 't / FOUNDATION_ <br /> LEACHING LINE OF USES � `� �- <br /> LINE <br /> SLIM BED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY <br /> MOUNDED ❑ TN LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE <br /> _ 1F FOUNDATION n f PROIERTY USE�� b/ <br /> SEEPAGE RS DEPTH L I SIZE NUMBFF_ ,3 DISTANCE TO NEAREST:WELL <br /> LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE <br /> SLMPS ❑WIDTH <br /> FOUNDATION PROPERTY LINE �e <br /> LLNOTN DEITN DISTANCE TO NEAREST:WELL f <br /> DISPOSAL FOMOS ❑WIDTEM (D <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE GONE IN ACCORDANCE WITH BAN JOAWIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN"AMIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE fOLLOWINO:'I CERTIFY THAT IN THE PERORMANCE OF THE WOOL FOR WHICH <br /> THIS PERMIT IS INSO FT I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPNBATON LAWS OF CALIFORNIA.' CONTMCTOR'B HIRING OR <br /> BUB-0ORTRACTI ONATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE KROBMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WQRKMAN'S CO P SATAN LAWS OF CAL FORNI�`APPICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE O"WINO BELS 1 <br /> y � 1wc TrrLE O W N DATE: <br /> SIGNED% <br /> PLOT RAN DRAW TO SCALE)SCALE_ Ie <br /> {. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. 6 LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPRtY OR ADJOINING PROPERTY. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. _ <br /> Nd <br /> J <br /> .0 <br /> r . <br /> ..I <br /> lLf 1998 <br /> NN L_ <br /> civ 6LL-^ <br /> I <br />