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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMU TO CONSTRUCT AND/OR INSTALL 111E WORK DESCRIBED. THIS APPLICATION IS MADE IN COMMANCE WITH BAN JOAWIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11'!11100.3 AND THE STANDARDS OF,SAN/JJOAA�GUUIN COUNTY PU C HEALTH SERVICE8.ENVIR O NMENTAL/HEALTH DIVISION, JOB ADDRE6B/OR AMI __// ��/�� / '�" / L<-�// / CITY �9 j `')'� /LOOT 81ZC °'r/— r OWNER'S NAME)LLJ\ �•P/11CJ'4�T- ADDRESS J,. �1 �J(PHONE?1l' 0-2-13 CONTRACTOR /\J\�T^ �' -1�� ,C^ ADDRESS 7 t. •I _'1� I v, .S�'i O�LJ L1CI L+ r'PHONE+ 57 � SUB CONTRACTOR ADORE 66 UC# MINE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITIONKj DCITRVC LION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF SUI NG.) PER.TESTIH 1 1 HOW MANY Apptle°tlen INSTALLATION WILL SEINE: RE SIOENCE COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UMTS: / NUAB91 OF��FED'ROOOMS: NI.MSER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET'_� PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TMP ❑TVPEJMFG ^CAPACr1YY NO.COMPARTMENTS MO TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL \ FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF.PUM�P. /S7AND OIL 6 :RATOR IENCL06ED SYSTEM)T— 1 LEACHNG UNE �NO.•LENGTH OF E6�/V✓ '7� STANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH _/bEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH GTH DEPTN DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 6EEYAOE ATS ❑DEPTH BRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PPOPERTY UNE awn ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PIY TH18 APPLICATION AN9 THAT THE WOFK WILL BE GONE IN ACCORDANCE WITH BAN JOAWIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REO T BOF THE BAN WIN OUIfTV.HOME OWN�Ejr LICE N8ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-)C ERTIFY T HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE IT IB I BU '4.BNALL T EM YAW PERSON M SKX A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S AIRING O0. SUB-C RACTI NATURE RTIFIES HE Fol IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOFK AN'8 CO N 8 OF C FORMA.' C T UST CALL 24 HOURS IN ADVANCE F00.A 11EOlI1R INSPE0i1 ONS. COMPLETE DRAWING BELOW. DATE' q. Z Z BIGNE % TNLE. PLOT PUN(DRAW TO--I SCALE_ I° 1.NAMES OF STREETS O AD ST TO OR BOUNDING THE PRROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL BY67EM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT.ON INCLUNNO COVERED AREAS SUCH AS ATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPEffTY. r/d'iA n GTS c•y-r" r��a, '" _ q� Ffi' I�• _ 3..1998 _. .. L .....�,.... ........... (t1Uh2(r IpUBLIC;IONM HEAL E�A.I71N'IDLV Sl"'.r-. _.. L... -� ..__ .._...._ .. ;.... .._;_. ....._. .. CESI ENVIf;ONMENTAI.i� ...,... ... ;.. ..[....._ ....... ... -- ...... d' FOR DEF-ENT USE ONLY A: APPLICATION ACCEPTED BY 'L�L�V !" �-'< DATE: TANK,P T OR SUMP INSPECTION BV DATE / FINIAL WS TON BY DATE. ADDITIONAL COMMENTS: / -� L ACCOUNIINO ONLY: AID# FACS PE CODE 77;� M AOVNT REMITTED CIIEC IC ASN RECFNFD BY DATE 611/PERMIT NUMBER INVOICE S �Il 73 Pub.Health Sam-Enviro.174(3/96)