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APPLICATION FOR LIQUID WASTE PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVICL ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 O (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IL:RIIro MTR In TrIpRe6t21 AAIICATtON IR HFIVAY MADE.TO THE RAN JOAQUIN COUNTY VOR A PERMIT 70 CONSTRICT AND/OR INSTALL THE WORK DESCRIBED. EMR APPECATION 16 MADE IN COMMIANCE WTH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.E AND THE STANDARDS OF RAN JOATRRN COUNTY PUBLIC HEALTH SE R VICER.ENVIRONMENTAL HEALTH DIVISION. .NIB ADDIUFSRMR ATNF cD Li�L%-n p1�Cc-- LA CT' •Y1"'CJ/�t'T'�l�l�� ^jLOTT RRF_LN=4Zq OWNER'S NAME �Q 1� �Is�FZV _ ADDRESS C3 PHONE . ll�Sl' 1Lio 7 CONTRACTOR Ie -}�- .:lM ADDRESS )� Y-'TT-^ UCP PHONE A-e 3`333 RUR CONTPACTOR A... -L ICI PNOMF TYRE OF Sr"C WORK RIM INSTALLATION ElRAAINADOITION FtTt DESTRLCTION❑ IAO SEPTIC SYSTEM F[RINGI ED IF PUBLIC SEWER ,_ WI IN AVAILABLE THIN 200 FEET Of BUBDINO.) FERC TESTNI 1 I HOW MANY t'-"i0 �j V APPSFBRFR0 INSTAILATION WILL SVFTVE: RfSOFNCF EA, COMMERCIAL❑ RIO2 OTHER T--/��✓\�I c MUNINFTR OF RIVING UNITS:_NUMBER OF BEDROOMS. J NUMBER OF FMMOYM: CNARACTER OF SOIL TO A DEPTH OF N FEET'cAyl-AI� PFTTNR(U�MP SOIL CHARACTER-Q �'7WATER TABLE DEPTH I OO SfMC TANKARFASE TRAP ®TYPEMFO ^^„'-r' - ll,),FL KDAPACIEY CX7 �]_ NO.COMPARTMENTS PKO TREATMENT PUNT❑ INSTANCE TO NEAREST: WELL FOUMOATION J L� PROPERTY LINE UFT STATION❑ STE TYPE OF PUMP BAND OIILSEPARATOR RNCLOSFO SYRTFMI LFACMNO U11i1y /NE B NO.\LfNOTN OF LINEt` IJy (j L MBTANCE TO WATERT:WFLLICX2_�_FOLINDAEION'j�ry DrfRty LINE loo, FILTER RED ❑WIDTH LNOTN DEPTH DISTANCE TO NEAREST:WELLFOU R OATION PROPERTY LINE MOUNDED (3 WIDTH_LEMTH DEP H DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LE SMAGE PITS Et 1.104 M2L�L NUMBER t_DISTANCE TO NEAREST:WELL 1��FOLINDATONLINE_ LINE C7 N SUMPS ❑WIOTH lE VFPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME DISPOSAL PONDS ❑WIOT14 tENOTH DEPTH DIRTAME TO NEAREST:WELLFOUNDATION PROPERTY Lw* - I HrOFRY CrMI It TIIATI HAUS MFPARSO TION AM CATION AND THAT TIIT WOE!'"IL RT MNE IN ACCOMAWf WHH SAN JOAOUIN COUNTY ORDINANCES ANO STATE LAWS.ANO RUUES AND RFOULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'R SIGNATURE CERTIFIER THE FOLLOWINO:'I CERTIFY THAT IN TNF PFPEOR MANCE OF THE WORK FOR WHICH THIS PERMIT IR IRRUEO.1 SMALL NOT EMPLOY ANY PERSON M SUCH A MANNER AN TO BECOME RIUBJECT TO WOW MAN'S COMPENSATION LAWS Of CAUFOIMA.' CONTRACTOR'S NNSNG OR SUR CONTRACTINRSIONA7URF F.NT IfRR THE FOLLOMNO:'I CERTIFY THAT M THE PFRKORMANCF Of THE WORK FOR MACH THIS PERMIT 19 ISSUED,1 FINAL EMPLOY PERSONS SUBJECT TO WORKMAN'S CON RAT.. �OF CALIFORNI • TIE APFUCANT MUST CALL M HOURS IN ADVANCE FOR ALL MOURm INSPECTIONS.COMPLETE U11AMN0 BELOW, 7�7 SKFNFDA 4 421TITLE: J 0v\F-"Z DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ -I- I NAMES Of STREETS OR ROADS NEAREST TO OR BOUNDINO THE PROPERTY. S.LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUVUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. �.DIAIENNIONFO OUTLINES AND LOCATION Of ALL fXISTMO AND PROPOSFO STRUCTURES, 6.LOCATION OF WELLS WITHIN RADN.Hl OF ONE HUNDRED FIFTY R.ON IMIUDNIO COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WAULB. THE PROPERTY OR ADJOMINO PROPERTY. f --- (Da's'L Izov 157z t '90 n�N¢ xoo _ ZL /I eel- ��9`✓ yn..'.u;.,.n:ION r.�,.i RnrIY .uPill,r r• n1 srrNvicrs -Nb'iIF�`nP+F N I'I urns FN nlVIpj ' 11 .:>. »17yzi p Ic± FOR DFPMTMFNT USE ONLY _ APA CA TION ACCFPTED By / EQ�L, DATE' ARTA:yI �'- 14 AUK) OR PUMP INSPECTION BY /(„(/ rN�G�T/� DATE J `I AL INSPECTION BV DATE / OA'.y �/ ADDITIONAL COMMENT ACCOUNTING ONLY: AUDI FACS 7 PE CDGE iEf IMO AM 1/NT RFMIITFO RC KA6N BECEVFD tY DATE SR F PERMIT NUMBER INVOICE I > 15-2-99