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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,446 N.SAN JOAOUIN ST.,STOCKTON,CA 96201.0388 (2091461-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompMtA in TriRicaul MPUCATNIN IS HERESY MADE TO THE SAN MAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOKI INSTALL THE WORK DESCPfiED.THIS APPIICATION IS MADE IN CGNIPU—CF WITH BAN JOAGUIN COL;NTY DEVELOP?.REIN��TRLF,CHAPTER S-1110.3 AND THE STANDARDSOFSAN JOAGUIN COUNTY PUBUC HEALTH BERVICCIFS,FNVIRONM/yE�NTAL HEALTH OMSION Df1 . JOB AOEB8fON DPN/ .3/ � L ��'/ CRY ./!Q C�/ d r LCT SIZE X T y OWNER'S NAME ADDRESS 3732 6 el- i PHOHE_ rrof CONTRACTOR a ^',L!YV7�.2 g. ADDRESS yob/��r� r�cA'��uuF�lt�3` PHoF:E 477 BUB CONTRACTOR_ ADDRESS LIC/ PHONE TTm or SEPTIC WORK: NEIN INSTALLATION❑ mo A vl orrION ❑ OFATRUCTION❑ ! INO SEPTIC GYST13A PERMITTED W PUBLICSEWER ISAVAILABLE LMHIN Z—FEET OF BUI DING.( / II POW TFSTN)(7 HOW MANT O• AC7Pr�'rrf( o—^ v -i'- /4i r LIQ,.,f' /y01� ARpNanbn F_ INSTALLATION WILL 4WVC RE&DEWE❑ COMMERCIAL❑ OTHER❑ err NUMBER OF LIVING WITS. NLVARM OF BEDROOMS: NUMBER OF 061►L.GYIMS CHARACTER OF SOIL TO A DEPTH OF D FEE.': PTISUMP SOIL CHARACTER. WATER TABLE DEPTH_ SEPTIC TANKMAEAIE TRAP ❑"IFNAF4 CAPACITY Na.COIAPARTFIEWTB PRO TREATMENT PLANT❑ INSTANCE TO NEA\pT: WELL FOUNDATION PROPERTY LINE 0 LWT STATION SIZE TYK OF PUMP SAND OIL SEPARATOR(ENCLOSED SVSTEMI _ LEACMNO WE ❑ NO.i LENGTH Of UNEB OIBTANCE TO NEAREST:WELL FOUNDATION PFI ATY LINE FILTER POD ❑WIDTH LE]NOTM DEPTH DI6TANGE TO NEAREST:WELLFOUNJATION PROPERTY ME MOUNDED ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIRE SEEPAGE RTS ❑OFPTN SIZE NU MFIER OIBTANCE TO NEMILST:WELLFORMDATION PROPERTY LINE SUMPS ❑WDTN UNOTH__DEPTH DISTANCE TO NEAREST:WELL__FOLMDATION PROPERTY LINE WIDTH— DISPOSAL PONOS ❑ LENOTH _DEPTH DISTANCE TO NEAREST:WELD_FOUNDATION PROPERTY LINE ` I HEREBY CFRTIFY THAT I HAVE PREPARED 1416 APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WRN SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AN MFLEA AND REGULATIONS Of THE SAN JOAQUI N COUNTY.HOME OWNER OR UCENSED AGENT'S LRGNATURE CERTIFIES THE FOLLWANG:'1 CERTIFY THAT IN THE PERFORMANCE OF TIE WORD POR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A W4NNER AS TO BECOME SUBJECT TO WOMMAN'S COMPENSATION LAWS OF CAJFORMA.• CONTRACTOR'S HSBNO OR e1/BtONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIE WORE FON WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOR(MAN'S COMPENSATION LAWS OF CAUFOFWIA.' TFE APPICAMT MUST CALL 34 HOURS IN ADVANCE FOR w.MOUARED INSPECTIONS.COMPETE DRAWING BELOW. 81ONED kmss/ TRLE:f d✓/hr�l�/` DATE: PLOT PLAN(DRAW TO SCALE)SCALE_��is L�G'U 1.NAAAES OF STREE78 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION Of HOUSE SEWAGE DIST06AL SYSTEM OR PROPOSED 2.OUTUHE Of THE PIOPRTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF 5EVMAGE DISPOSAL SYSTEMS (\ Jf 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURC S, - 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ff.ON INCLUPINO COVTRFD AREAS SUCH AS PATIOS,DPWEWAY5,AND WA KR. THE PROPERTY OR ADJOINING PROPERTY. 7Hl/. .. � .. .. . . ......... �I . ..., rat E�f..B�✓�'.y �t .......... ...... .. ..; . . .;.. .. X000 :.... .:. .� ' .......... Ira f ... v... . ....... ......__... ........:.. ..... ..... .... PAYME:N7 ....._....,. ' ........... RECEIVEn :...._..... ; ... .: ............. . .. FEB 2..8...I ...................... SAN J4AQLlIN C�3U;N7Y . • .... ..:.PUBLIC HE.LTH SE.FTWES ..........:.... ENVIRONMENTAL HEALTR DIVISION POR DEPMTNE/T USE ONLY APPLICATION ACCEPTED B'! L DATE TAM,PT OR SUMP INt,P ECTIO1N BY DATE I I FINAL INSPECTION DATER1 r I I AODITN]NAL COMMI.NT6:3.3 lkajI �'G'"�Q � fit L (LI ✓ -: T I `` /.f ACCDUNT'.NO ONLY: AIOM FACT �LyG � • /•rsF PE Cf.OE FEE INFO AJWI IT FWATT CHECK/ ASN REG Y DATE BR I PBLMR NUM6E1 IN—C I : Sy