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F-� APPLICATION FOR LIQUID WASTE PERMIT SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 380,446 N.SAM JOAQUIN ST.,STOCKTON,CA 762010380 (209)488-3420 ROWREFUNRARLE PERMIT EXPIRES 1 YEAR FROM RATE WHO OBOISTS It 7riT9tttt) APPUCATTLW IS HEREBY WIDE TO THE BAN JOAQUIN COUMY FOR A PERMIT TO CONSTRUCT^140,011 INSTALL THE WORK DESCRIBED.THIS APPUCATgN IS MADE N COMPLIANCE WITH SAN JOAOIRN OO!JNTY DEVEID'P77MENT TITLE, CHAPTEEF;0-1110.3 AN THE STANOAADS OFF JCAOUN COUNTY PUBLIC HEALTH 81EIVICES,ENVIRONMENTAL HEALTH DIWO113N. J00^DOIE651DR A44PNA�f (�- C - �.� /'a•Q/L. F"+C.( CITY V LOT Sf>f E rte'/�//�J-•�' OWNER'6NAME4,•7T 7 ADDRESS L S-7,. PHONEgy CDNTRALTOR/ t.1, //ti/y �J7� 'e— ADOWSS/w- ch,. .// -7,. Uct BUB CONTRACTOR ADDRESS LIC. RHONE TYFE OF GWFIC WORK: IOW INSTALLATION REFAIIVAODrTON❑ OBSTRUCTION❑ NO SEPTIC SYSTEM PERMITTED if PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF WAIDING3 FRC TMT1.L 1 ROHM MARY AwSafSPR i INSTALLATION WILL SERVE: REOIDIN LZ V COMMERCIAL Q OTHER❑ ^, NVA56t OF LIVING U FTS:__L_NL%WM OF 1113DROOMS:,2 NONSR OF BMRDYEEB: J L BOIL TOA DEPTH OF 3 FELT: PIT 16UMP SOIL C HARACTER:lE9/1..STLA�./I WATER TA®J:DEPTH tSPIIO TM E TMF ❑TYFEwa LAJ'ACRY Z, C/ !i/�/ NO.COMPARrM'JlTS CJ{ 1555NT RANT❑ OIBTASICE TD NEAREST: WELL /D/)/ FOUNDATION �� PROPERTY VN! LFT STATION❑ BRE TYFX-OF PUMP SAID OS.SEPARATOR IENCLOSED SYSTON LEACHING UNE W.S LENGTH OF tJNES �///APa S DISTANCE TO NEAREST:WELL/OD FOUNOA-m"30 PItlPERTY LYff RLTR BW ❑WIDTH LENOT• DEPTH__ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY WE 10"NOW X13 vvvDTH LEWTN DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE_ SWAGE R !TS yLptmm 215" SRE-1 �-NUMBER_ 7 DISTANCE TO NEAREST:WELk� r FOUNDATION 70, PROPERTY LINE IM �O I SM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PON" ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL _FOUADATION PROPERTY UNE 1 HERESY CERTIFY THAT I HAVE PREPARED TFNB APPLICATION AND THAT T ItC WILL BE GONE IN ACCORDANCE WITH SAN JOAOVN COUNTY ORONANCEB AND STATE UY/0,AND RULES AND REGULATIONS OF THE SAN JOAOUN COUNTY.HOME OWNER OR U2: ED NT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY TH AT IN THE PERFORMANCE OF TN E WORK FOR WH ICH THIS PERMIT I ED,I SHALL NOT IN SUCH A AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SU TING S CERTI THEFO WINO:'I CERTIFY IAT N THE PERFORMANCE Of THE WORK FOR W HK:H THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOW 't CO_ TION T CALL R HOW IN ADVANCE FOR ALL NEOIREO NSFBCnONS. COMPETE DRAWING BELOW. $IG X _ TITLE:�af� DATE: POT PLAN(DRAW TO SCALEI SCALE _ 1.NAMES OF STREETS OR RO AREST TO OR BOUNDING THE PROPERTY. ^.LOCATION OF ROUSE SIEWAOE DISPOSAL SY.OR PROPOSED 2.OUTLINE OF THE PROPERTY,WTTH OIMEHNONt AND NORTH DIRECTION. EXPANSION OF SEWAGE b1sp4 SYSTEM. 3.DIMENT MFD OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUNE6, 6,LOCATION OF WELLS WITHIN RADIUS OF ONE HUIIORED FI .ON NCLUDIFIO COVEALD MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ago".T/L . ...................... ... .....:. ... ..._ .. . .....:.................................:.. ... .. - ..... .......... ...... ... ....... ....... .:.. ...:.......:...... .......... \ .............n..... ... ...... .............. ................ . :.... M..N4. .... ;... ..:....... ............. ; ......................:.....: ............. ...... ,....................... ...... �liBtiTC HPAtTH-S59.-ICS A......�..:....... cNdIRbNMF_NTAL HEALTH dLVIS K ................ .......,.......:... ................. . . 'o tas I FOR OSPANTIMIXT USS ONLY APFUCATXNi ACCEPTED BY \+• �� DATE: TANK,PR OR SUMP INSPECTION BY DATE 1 I FINAL INSPECTION S L DATE O S ADDITIONALCOMMENTS: lYf2f /ti. l, A ACCOYIFTEtO ONLY: NDP FMA' PF t�OE FEE INFO AMOUNT REMITTED IEC AAH RECDVEO BY DATE IIr -1—T NVOICt i a3a