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`l 0� APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209) 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YfAR FROM GATE ISSUED <br /> tce wIA8F in TfI Ita) <br /> APPLICATION 18 hERf RV MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS AV"(CATION IB MAZE M COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY OEVFLOPM4W TTrFLE.CHAPTER B•1110.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PI/BLIC HEALTH smVVICES,ENVNONMI HEALTH O"v?DN. <br /> .118 ADORE9S/OR APN, // L5L .__Ll'1d•- ` . CAY Z-K� —I I SIZ�Ei_ <br /> ("4FR6 NAMEyA-'/S L pHvNIE IL .L.yJ_Cjl, <br /> PONTRACTOR ADDRESS—Y--�-' n r` LIC• L� __PHONE <br /> CO NTPACTO R__ _r� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'K REPAMADOITION❑ DESTRUCTION <br /> IND SEPTIC SYBT EM PERMITTED IF Pl18L�C SEWER 18 AVAILABLE WITHIN 200 FEET OF RDILDING.I P61T.TEITI111 1 NOW MANY--- <br /> t apMa•no(. <br /> ;vSTALLATION WWII fClT AF-F; NI SIi IFN<.h COMMf-.IAI I.I <br /> P'uubfR OF LINN/I utifTB /_- NUMBER OF ff(1RDOM8 __�_ NIAVIli.#OF DIRPIOYFFI <br /> Ts <br /> I MARACTFP OF Soft TO A OEPTN OF 7 FEET' R MilSUMP SOLICH APgCTER_ '_' WATTR TABLE DFP1_ <br /> T1 _p ` <br /> REPRC TANK)ORf Aaf TRAP ❑TVf4,N.1(G _ - fAFAI;I I'f �,� {'} _NO.COMPARTMENTS o17- <br /> 9N0 TREATMENT n ANF❑ DISTANCE TO NEAREST V.'FILf011NhAilON r fM10F4liTY LN*�E -f'2' my <br /> LFT STATION❑ SIZE TYPE OF POMP—L-414 OIL SEPARATOR(ENCLOSED SYSTFMI ` <br /> LEAC14NO UNE NO.S LENGTH OF LINES_y1_x/220 I DPBTANCE TO NEAREST:VJEL FOUNOATMN�i PROPERTY UNE U J <br /> FILTER ISO ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:NEIL '-FnUNDATION PROPERTY LINE Cis <br /> MDUNOED ❑moTH LZINI _UFPTH INSTANCE TO NEAREST:WELL +FOUNDATION HgP"rY LINE <br /> SEEPAGE MTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LIME- <br /> LUMPS 1111 WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PFOPERTY UNE <br /> -dap SAL ❑PONDS VADTH LENGTH DI:TTH DISTANCE TO NEAREST;WELL-Y FOUNDATION PROPSRTY LINE <br /> i <br /> I HOMEY CERTIFY THAT 1 HAVE PREPARED THIS APPICATION AND THAT THF.WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUN COUNTY(IPOINANCES AND STATE LAWS,AND(RILES <br /> AND REGULATIONS Of TV*SAN JOACUIN COLWrY.HOME ONMER Oq L)CENSEO AGENT'S BPONATURE CERTIFIES THE FOLLOWING:'1 CERTITY THAT IN TNS PEIOMINIANCE OF THE WORK FOq WMCII <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNEN AS TO BECOME SARIJECT TO NW PKMAWB COMPWBATLDN LAWS OF CALWOPMA.'CONTM.CT .HIBNO OR <br /> SU&CONTRACTINO SIGNATURE CORTFI[S THE FOLLOWWO:'I CNFTFY THAT IN,w PERFORMANCE OF THE VMOK FOR LNBCH THIS PERM(f IB ISIUM,I SHALL EMM.OY PVWNS SUBJECT TO <br /> WOIKMAN'B COMP4NSATTIION LAWS <br /> OF CCA�UFO�RRNNffA..'jTHHE APPLICANT MUST CAU.24 HOURS IN ADVANCE PI ALL KAL/ISD INSPSECTIOlIIA.WI <br /> . COMPLETE DRNO BELOW. C Q. <br /> SIGNED x C-"L ,�J /-"e_'�''-"�'fl?./_ TrlE: ee-,�(, i L DATE: -5 <br /> NOT PLAN(DRAW TO SCALE(5CA:E 'Is <br /> 1.HAWS OF 6TREFTS OR RDADS NEAPFST TO OR ROUNDING TILE PROPERTY. T`- A.LOCATION Of HOUSE SEWAGE DISPOBAI SYSTEM OR W PORED <br /> J. OUTLINE OF THE PROPERTY,YNTH OIMFNSIONS ANO NORTH DIRECTION. Ne <br /> TION. FAFASION Of SEWAOE DISPOSAL SYSTFM . <br /> ]. DIMENSIONED OUTUNE6 AND LOCATION OF ALL E)1187MG ANLL PROP06FO RTRIICTURFP, S.LOCATION Of WELLS'ANTHN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRYVEWAYS,AND WALKS. TIE PROPERTY OR AD"MING PROPERTY. <br /> Imo^ Y� <br /> hDL�S2 <br /> MAA�E�r�6�0 <br /> I�{FP! (' <br /> 'Q o >ra 11r <br /> O_ <br /> Fe►Lc <br /> FOR DEPARTMENT 118E eMLv L <br /> APPLICATION ACCEPTED BY DATE: 1_ j_r AAEA;_ 1 V <br /> IANK,PIT OR 80/1 II'M IDN RYrr�_ (� DATE 1 I FINAL LH.C.TION I DATE R ll f3'7 <br /> ADDITIONAL COMMENT 1: 'v"Y/1'S� <br /> ACCOUNTING ONLY: MIDI FAC• <br /> CODE FEE INFO AMOUNT REMITTED <br /> 94CK ASH RECOVm BY GATE M f PIRMT NUMMI `, INVOICE <br />