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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PD.BOX 988,304 EAST WEBER AVENUE,STOCKIM CA 9SMI- 8 12091 401.3420 NON-11KFUNDARLE P R IT EXPIRES 1 YEAR FROM DATE ISSUED ICImpIItA III TTlplkztll APPLICATION 18 FEFEBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOKIR INSTALL THE WORK OEBCmBED. THIS APPLJCATION IE MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY.'1EVELOPMENT TITLE,CHAFFER 9-,,1Q1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVPWJN. JOB ADDREOWOR APN.f j �® `jq/Z P Ey�'G 2. ,l?^ Cm .1[Ll C-G-ruil/ _LOT wt `� OWNER'S NAME, A,r-�"/aL".41wi ADDRESS �E !{�� .{ PHONE CONTRACTOR/j (ry&'r DtEjf�� .��E88-3SJC� Ll&-L�fI/+'1!f'✓ /,v 17' LICE /a /'�J SUB CONYRACTDR/ )l fZ'I I J 1 8r ADORE58_T UC/ • Q_"NE TYPE OF SEPTIC WORK: IREW INSTALLATION REPMRIADINTON❑ DESTRUCTION❑ NO SEPTIC SYSTEM PERMITTED IF PU&IC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) OTIC TESTkI l 1 KIOW MANY �y�.' v [�j�� APIAar.tlonJ INSTALLATION WILL"RVC: RESIDENCE U COMMERCIAL❑ OTHER L'I A'W,6.h1 ///�4 NUMINBt OF LMNO UMTI: NL4IOM OF BEDROOMS: NUMSIP OF PAPLOYEEA: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ PITMUMP SON.CHARACTER: WATER TABLE DEPTH IfTTIC IAN ALE TR-- ❑TY7'EIMFO� 7 t L L(J!�'N�C--�CAPACITY �fj� NO.COMPARTMEN78 � V PKO TREATMENT PLANT ClU DISTANCE TO NEAAEl7: WELL FOUNDATION PROP;REY UNE Gj RFT STATION Cl BUT TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHNO UNE ❑ NO.S LENGTH OF UNES� DISTANCE TO NEAREST:WELLFOUNDATION PROPEATI UNE ry.. FILTER SID ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELL FOVNDATION PROPERTY LINE WOUNDED 13 •��WROTH LENGTH _DEPTH OIBTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE (� SmAOE PITS L.K DEPTH IRE--NUMBEP DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ) SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LJNC DISPOSAL PONDS ❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOOL WILL BE DONE IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE IT SAN JOAQUIN COUNTY.NOME OWNER OR UCENf1ED AGENT'S 91ONATURE CERTIFIES THE PJLLOW MO:'1 CFNTBYTHAT N THE PERFORMANCE Of THE WORK FORµMICH THIS PERM19 ISSUED.I W ALL NOT EMPLOY ANY PFRBON IN SUCH A MANNM. MANNED AS TO BECOME SUBJECT TO 10CIFFLMAN'S COMPENSATION LAWS OF CALSOR .' CONTRACTOR'S MRING OR BUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORN FOR WHICH TH18 PERMIT IS I89MD.1 SKULL EMPLOY PERSONS SUBJECT TO WORKMAN'S CONFER�ION,I/A/♦WB Of CAUFORWIA.' THE APPLICANT Mlu LMT CALL BA NOuIN ADVANCE FOR ALLRMUIARED ITMIS PWIRO . COMPLETE DR.LURND BEL'O/W. / SIGNED% L�i" /�-�/.� TITLE: 7�J DATE: ROT PLAN IORAW TO SCALE)SCNE 'IN TT 1.NAMES OF STREETS Oft ROADS NEAREST TO OR BOUNDING THE PROPERTY. A.LOCATION OF HOUSE SEWAGE DISP08AL SYSTEM DR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DSECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENBIONFO OUTLINE8 AND LOCATION OF ALL EKKTINO AND PROPOSED STRUCTUREB, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDINO COVERED AREAS SUCH AS PATIOS,DFJVEWAYB,AND WALKS. THE PIOPEPITY OR AOJONNG PROPERTY. Dli/v� SYU2NgyE VVI 4.1995 . J.: i SE. G.. EIJ _ PU , : 1. PON DEPAATMFNT USE ONLY APPLICATION ACCEPTED BY 1_-- -�f DATE: s TANK,PLT OR SUMP INSPECTION BY OAT E_ / I FINAL INSPECTION BY t1ATE /J Z7 1 ADDFTIONA CO:NMEHTB: /1-- /i//�a._T C✓ SIS-✓W7+'� V "NONLY: AID/ FAC/ vim` PL GOOC P AMOUNT 9HWXIAABH ABH RECEIVED BY DATE M f P6MKT NUMSR IINOK:E J 'I A,