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T P.- APPLICATION ._ ' rr.cax:, b' APPLICATION FOR LIOUID WASTE PERMIT SAN JOAOUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)458-3420 I1011-REFURDABLE PERMIT EVIRES 1 YEAR FROM DATE ISSUED KomgMIS M TrVReltm) APPLICATION IB HEPESY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND,OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH DAN JOAOUIN COUNTY DEVELOPMENT TRIS CNAPrE11 B-11110,.3 AND THE RANDACO�.._��OF�SAN JOAOUN COUNTY PUBLIC HEALTH SHINCE4 ENVS/gNMENTAL HEALTH W"910N, JOS AD0/1EDBAR ATNF.L�375 � W/ /O((, CRY l��J LOTDUE 'D `Lr{��/ O V%'S NARK bAV e 15C-HA AGGRESS / /� /�/� )T } PHONE�.J_7Z j CONTRACTOR '5 1/ / ADDRESS 23 r i `_�1 I I d u—) UCS RHONE / SUBCONTRACTOR ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTAILATGM❑ REPANADIXRON❑ OESTRUCTGN (NO SEPTIC SYSTEM PEAWTTE0 IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF RU VJNNO.) PSIC TESTISI I 1 NOW MARY APPSFAOFn/ INSTALLATION WILL"RVE RESIDENCE❑ COMMERCIAL❑ OTHER❑ MIMOSA OF LF.'M LINTS: NUMBER OF BEDROOMS: NIIMSSA OF EMPLOYEES: CHARACTER OF BOO TO A DEPTH OF 3 FEET: PT/BUMP SOIL CHARACTER: WATER TABLE SEPTIC TANKMIREASS TRAP ❑TYFUMFO CAPACITY NO.COMPARTMENTS ►Ka TREATMENT RANT❑ DISTANCE TO REARM: WELL FOUNDATION PROPERTY LIN UFT STATION❑ SIZE TYPE OF RMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAPEBT:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH USTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUND® ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PRS ❑DEPTH BUE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE W DIIFOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:NRI. FOUNDATION PROPERTY LINE — I HEREBY CERTIFY THAT I HAVE PREPARED TM APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCF WITH SAN JOAOUIN COUNTY ORDINANCES AND BTATE LAWS.AND RULE; ANA MGG ATIONS OF THE SAN JOAQUIN COUNTY. G ROME OWNER OR LICENSED AGENT-S SNATURE CERTIFIES THE FOLLOWING:7 CERTIFYTNAT W TIDE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS rSMOEO,I SHALL PHOT EMPLOY ANY PERSON IN BUCK A MANNER AS TO BECOME OMACT TO WORKMAN'S COMPENSATION LAWS OF CALIPOFNA."CONTRACTOR'S HRIG OR ([�( SUBCONTRACTBG SIGNATURE CERTFIEB THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT N ISSUED,I SHALL EMPLOY PERSONS M16JECT TO 1 l' WORKMAN'S COMPENSATION LAWS OF CALFORNI THIN APPICART MUST CALL N HOURS IN ADVANCE FOR ALL IN--INSPECTIONS. COMPLETE DRAWING BELOW- BORED x- �l/'�� TIRE: fh �4 1 DATE./ — 2 2--0 3 PAT PLAN DRAW TO DCALE7 SCALE "to 1.NAMES OF DTREFTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4-LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE F OPERTY.WITH DIMENSIONS AND NORTH INRECTIDN. ERPANIION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED SrRUCT1IRES, S.LOCATION OF WELLS WITHIN RAOM OF ONE HUNDRED FIFTY FT.ON INCLLR)m COVEF&D AFEM MUCH AS PATDI,FIBVEWAYS.AND WALKS. ._. _... .. .......e......:......b......i....-i-....., THE PROPERTY OR ... .. .>..... ......... ............... ... -... '�. •• ...:... '.......i......�...... .t.V.'.. .....:....... ... ... ....... ....... .r r... '.... ,. .... .,. .-i ...........y.... e..... ......E... .' i.-v►V'u... pQ .. . Q i .... l a.... -.. .....;......y...... . ... .................>.. ..... . •....o (( ..... �f ........<.....P �� F. .. 0 .4 L.K` S ttlN ....� ..._ ................... ;.... :...... ............ .. .........._ . ............... . PON DEPAPWMT USE ONLY 2I ! 0�`�9 A (CATION ACCEPTED BY DATE: ATIEA� TANG,PT OR MIMP mSPECTION BY DATE I I FINAL INSPECTION NY DATE 1 ADDITIONAL COMMENT'S: I. J ACCOON7110 ONLY: ADI FACE R CObE FEE I o AMOUNT REM71 TEDCIECK1a ASH RB9Vm OY DATE M I PeKBT KUMBE R IRVOICF F X02T7-T- oo Lf6 ' 7/c 3,51('00Sa 7 7 /07-- c G Pub.Heetth Serv.-Elmro.174(3/96)