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00C/-5 C/ APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 988,904 EAST WEBER AVENUE,MCKTON,CA 95201388 (209)468-3420 MOWREFUNOABLE PERW EXP( S 1 YEAR FROM OATS U 25- A ff (CempNb ie TrylWW APPLICATION M HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 A14D THE STANDARDS OF SAN JOAQUIN COUNTY'u.LL1C•y�y'j'EALTH SERVICES. ENVIRONMENTAL HEALTH DMSION. JOS ADDRESSIOR APP�NNy# _� -;-a�/–�/TP1 / cJ,+)/0� D�^/�J / \.y�15� [�/ 4 �`�" LOT SIZE_�J/ OWNER'S NAME Ayw h,'Ck, ( (f�C.r L" _ADDRESS 437 < �V I/'s C� _ PHONE 22a 7 2YN13 CONTRACTOR /JIJ 1V\e Y ADDRESS_ ") ��LN:I PNOHE SUB CONTRACTOR ADDRESS Lk:f PHONE TYPE OF SEPTIC WORK: NEW NNTALLAMN❑ REPAIRlAOpTION 0 O"TRUCTIOM CNO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVNLASLE WITHIN 200 FEET OF BUILDING.( Pelf—T(.)I 1 HOW MANY AgpSa4ft.f INSTALLATION WALL SEOYVL RESIDENCE❑ COMMERCIAL ElOTHER 13 14WROI OF LANG UMTS: NUINAM OF REDROOMS: NUMAM OF EMPLOYE.7: CHARACTER OF SOIL TO A DEPTH Of G FEET: PrT/SUMP SOIL CHARACTER: WATER TABLE DEPT SEPTIC TANKIOREASE TRAP ❑TYPEAMFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO WARIEST: WELLFOUNDATION PROPEITY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM$ LEACHING UNE ❑ NO.B LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME FRT@R Sm ❑WIDTH_TTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNTED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PIT& ❑DEPTH SUE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREBT:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:VYELL FOUNDATION PROPERTY UNE 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCGAOANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEWOWAAWE OF THE WON(FOR WHICH THIS PERMIT t8 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CAUF*MIA.- CONFMCTOR'B HSVNO Oft `jJ SUPCOW RACTINO RK SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFOR WHICH THIS PERMIT W ISSUED,1 SHALL EMPLOY PERSONS BUBJKT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL PWOUIRED�NTNRCTIONS. COMPETE MAWIHO BELOWks, . SIGNED X L"'"N � TITLE' �l� W DATE: POT PLAN(DRAW TO SCALL]SCALE ',n 1.NAMESOF STREETS OR ROADS NEAREST TO OR BOUNDNO THE PROPERTY. 4.LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OVTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOBAL SYSTEMS, J. DIMENSIONED OUTUNES AND LOCATION OF ALL DUf"NO AND PROPOSED STRUCTURER, S.LOCATION Of WELLS WITHIN HAD"OF ONE HUNAREO FIFTY Ft,ON �L INCL.UOR10 COVERED MEAS SUCH AS PATIOS.DNVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. icy✓ V RECEBTFl- ,NUL 22 1998 �. $ANJWUIN CQUNTI ... P(IBUC HEALTH SEIAVICES-: y` .......... ..... .... DEPARTMENT LME ONLY - APPLICATION ACCEPTTD RY ` - DATE: Z- lk A'FANK,)Prr OR SUMP INSPECTION BY 1/1 t� DATE /,'I FINAL INSPECTION B-I GATE ! I Y ADDITIONAL COMMENTS: Cor" ACCOUMTINO ONLY: NDf TACE PE CODE FEE INFO AMOUNT REMITTED 4 7ZW&9*CASH MOVED BY DATE SR I PF7tMT NU.401 INVOICE f rG2 a�6 g -7.i-2 ff R6101 1.3.g '