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APPLICATION FOR LIOU10 WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTOK CA 96201388 <br /> (209)UB-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR HMAII DATE ISSUES <br /> RMRplets Is TtWWts) <br /> AP LCATON If K.RERY MADE TO THE MAN JOAOUIN COUNTY FOR A PERM-TO CONSTRUCT ANDA3R WMALL THE W01K DEOCRIND.THIS APPLICATION NI MADE IN COMPLYANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TIRE.CHAPTER P 1110.3 AND THE STANDARDS OF SARIN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMIMON. <br /> JOB ADDRESM,OR APNO 700 7 ((.) a� /fJT.I. l (��E+.�� CT!_y�T�r_l� J _/LLOTnSi2e�' <br /> OWNER'S NAAE �� !% ilk �] ADDRESS �L��/ PIWAE f!!e,?2�LV <br /> CONTRACTOR�-(A.Sr"!/i • F ADDRESO <br /> SUS CONTRACTOR ADDRESS UCI P101E <br /> TYRE OF elfTIC WORK: NEW INSTALLATION❑ PtWANUAD0n0lI,.K ouTTIUCTIGN❑ <br /> IND SEPTIC SYSTEM PFIWITTED F PUBLIC SEWER IS AVARABU WITHIN 200 FEET OF BINDING.] PYIO TBMTNi I 1 HOW AURNT <br /> A/SMPPS'PR� <br /> INSTALLATION WILL 661VM: REs10ENee L COMMERCIAL❑ OTHER❑ <br /> wAnm OF WINO UNITs: 7.- N wmm OP sELIIIDOMI:�of' N%AMm OF/AROY6is• <br /> CHARACTER OF IabK TO A DEPTH OF�JF RET:�l,AV�J_{ PrTMU.IP ODIC CHARACTER: �J WATE11 TABLE pEPIH <br /> SEPTIC TANK/SICASE TRAP Z7YPUUFO_`7"/— S[ A' CMACETYpLw NO.COM.PARTWNTS'I <br /> PRO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION P/OFIHTY UNE <br /> UPT STATION❑ &IE TYPE OF PPDAP SAND OIL BEPARATOR tENCLOSED MYSTEMI <br /> LEACHING UNs ❑ NO.M LENGTH OF,LNEe__ DISTANCE TO NEAREST:WFIL FOUNDATION PROP13"LINE <br /> TUBI was ❑WIDTH LENGTHOEPTI DN-ANCE TO NEAREST:VJFLL _FOUNDATION PROPERTY LINE <br /> MOLINOSD ❑WIDTH LENGTH —DEPTH DISTANCE TO HEAREOT:W%LL _FOUNDIOUNE <br /> GE <br /> ATN PIOPENTY <br /> SEEPAFITS 11QM <br /> bERH 9E _NUMBER DISTANCE TO NEAREST:YELLFOUNDATION PROPERTY UNE <br /> SLIM ❑WIDTH LENGTH OETlH DISTANCE TO NEAREST:WELLPOUHDATION PPOPERTY LAE <br /> DISPOSAL PONDS 13,"" LEHGM D,'PTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UPW <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APRICATON AND THAT THE WOW WILL BE DONE IN ACCOROAJNCE'NTTH MAN JOAONH COUNTY ORDINANCES AND STATE LAWS.AND IDLES <br /> AND REOULATONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LCENeEO EN <br /> ANT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CENTIFYTHAT INTHE PERFORMANCE OF TI(WOIK FOR WHICH <br /> THIS PEOMMT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME OUMJECT TO WOFAMAN'S COMPENSATION LAWS OF CALIFORNIA.' COMFkCTO"HIRING OR <br /> SU"DMRACTMO SIONATURE CERTIFIES THE FOLLOWSNO:'I CERTIFY THAT IN THE PERFOFMNANCE OF THE WD'AK FOR V*MH THIS PI RILMT M ISSUED,1 SHALL EMPLOY PVWONS SUBJECT TO <br /> WOFKMAN-I COMP KATION LAWB OP CALWDM&- THE APPLICANT MUST CALL 24 MOW M ADVANCE NM ALL RMOUMSD POPECTIOIN. COMPLETE OMYNNG BELOW. <br /> SIGNED X / TT.U: Gl�� DATE. /• <br /> ROT RAN DRAW TO SCALE)SCALE .to <br /> i <br /> 1.NAMFS OF 7IREET8 OIU ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF"OUSE SEWAGE DISPOSAL MYMTEM OR PROPOSED <br /> 2.OWUN <br /> E OF THE POPERTY.VKTH DWENOONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL NYSTEMS, <br /> 3. OIMENSONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUNEe, M.LOCATION OF WELLS WR'THN RADIUM Of ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED MCAS OUCH AM PATIOS.LIII VEWAYM,AND WALKII. THE PROPERTY OR ADJOINING PROPER Y, <br /> .: .• .. a <br /> y�ei :rd <br /> . y <br /> CES <br /> ...:....; _ .. i....: I�UM1::..:. <br /> .... :.... :...ENVIRON,EN AQL.HFAL•2�H IDN <br /> fie. .. . : .... + <br /> ....:........... <br /> i ... .. ; ..... <br /> '� <br /> FOR DVAPPTBBi►E EPN WAY <br /> APRIL ATION ACCERTED BY )ATF: AREA:_ <br /> � 1 <br /> TANK,PTR OSUV.P INSPECTION BY BY DATE FININSPECTION SY DATE2— I zf ,g <br /> ADDITIONAL COPAWNIO: <br /> ACCP UNTINO ONLY: AUDI FACT <br /> .E CODE FEE INFO AMOUNT RFIVITTEDNEC ASH RECRVED MY DATE M I PlTST NtINI.9R INYDIC9IT <br /> !o / S el *305 3�9L / <br /> 3 <br />