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t)� APPLICATION FOR LIQUID WASTE PERMIT <br /> l7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-MUROABIE PERM17 EItMRES I YEAH FROM DATE ISSUEO <br /> r-omp1MtB M Trip WI@) <br /> APPLICATION 1/HEREBY MADE TO THE SAN JOAQUII COUNTY FOR A PERARIT TO CONSTRUCT ANDMR INSTALL THE WORK VEDIC RED. THE APPLICATION m MADE IN COMPLIANCE 14TH RAN <br /> JOAWIN COIAYTY DEVELOPMENT TITLE.CHAPTER B-1110.3 AND THE STANOAMS OF RAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENNPIOHMENTAL HEALTH COVIRION. <br /> JOB ADDREBSIOR AFNI le)9C! CITY jy-wtj1a' POT SIZFarJ , <br /> OWNER'S NAMEZ'ILLI1 ,�/TJ/'/C A•'✓ ` AnOREBRs�lyyy,1. PHONE_ <br /> Wt <br /> CDHTAACTDR •�. J-� JS+ai AOEee�/19 Z;j& /34111l C. 04- LIC/..VS-7Q YE PHONE 3452-15-027 <br /> RUB CONTRACTOR ADDIV99 UC• PHOS <br /> TYPE OF SEPTIO WORK- NEW INSTALLATMN D REDAIR/ADOMON (�y O DESTRUCTION ❑ <br /> INO SEPTIC SYSTEM PERMITTED F PUBLIC SEWER 19"ARABLE WrTHIN TOO FEET OF SWLDI+O-I PMC TESTIO I 1 HOW MANY <br /> APPB-eun 9 <br /> MSTALLATMN WILL SERVE RESIDENCE 19 COMMEIRCLAL ❑ OTHER ❑ <br /> NUSMSER OF UVINO LIMT& I NUM\9t OF BEDROOIW: WOMEN OF EMPLOYM: <br /> CHARACTER OF SM TO A DEPTH OF 3L FEET:_ PITISUMP BOIL CHARACTER: WATER TABLE DEPTH <br /> SPTK'TANKIQRX lr TRAP ISTYTE/wo JQJ}Q 6641 CAPACrTY NO.COMPARTMEMS <br /> PKa TREATMENT RANT❑ DISTANCE TO NEARL�ST: WELL FOUNDATION HIOPERTY UNE <br /> LIFT STATION❑t�On TYPE lF PUMP •� "SAND OIL SEPARATOR IENCLOGID SYSTEM) <br /> IA _ <br /> LCNNO UNE a NO.A LENOTH OF LASS I ' 1-14ry+� �C DISTAWE TO NEJITERT:WELL FOUNo ATIONPROPERTY LINE,» <br /> FILTER BED Ll WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOIMOED ❑WIDTH LENGTH_ DEPTH DRSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 60"OE PRS RDEPTH S'SBE_ `1 WMWER__L `DISTANCE TO NEAREST:WEII UC• r,Ot1NDATRTN -7 MgPERTY LIRE NUG t' <br /> SUMPS ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LDIGTH _DEPTH DISTANCE TO NEAREBT:WELL —FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTSY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WALL BE GONE IN ACCORDANCE 14TH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND AMB <br /> AND PWIRJtTIONS OF THE BAN JOAOUN COUNTY.HOME OWNER OR UICENSE D AGF W'S SMNATURE CERTIFIES THE FOLLOVANO;'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PNMT IB ISSUED,I SHALL HOT EMPLOY ANY PERSON N SUCH A MAONER AS TO BECOME SUBJECT TO WORKMAN',COMPENSATION LAWS OF CALIOO"A.' CONTRACTOR-9 NSRNO OR <br /> SUB-CONTRACTINO SIONATURC CERTWWB THE FOLLOWING:7 CERTIFY THAI N TRE PERFORMANCE OF THE WORK FOT,WHICH TMS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS MM MT To C" <br /> WORKMAN'S COMPENSATION LAWS OF CCALJPOF*Ak' THE APPIIC"T MINT CALL DS HOURS W ADVANCE FOR ALL.RE+GIUlRED INSPWnONS. COMPLETE DRAWING BELOW <br /> SIGNED X �G��'C--1°JL TITLE:—4: yC .jy <br /> DATE: 4 <br /> PLOT PLAN DRAW TO SCALE)ItCALE <br /> 1. NAARS OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PIDPEATY, 4• LOCATON OF HOUSE SEWAGE DNPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH OIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. <br /> D, DNAENINONED OUTLINES AND LOCATION OF ALL EXISTNO AND PROPOSED STRMTVMC, 6- LOCATION OF WELLS WrTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> IICLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALLS. THE PROPERTY OR ADJOINING PROPERTY, <br /> t ..t.. Lr ... .... <br /> : ... <br /> .. ........ ..... i. <br /> i i <br /> ..�..,...i......1.•...:.... ......:.....v........... .. .. ...6.............s .. .. - : <br /> • t • i ...., ........ .. <br /> ty- <br /> S <br /> _..... 1 n.. ...... ... <br /> j <br /> : <br /> . `...... .. <br /> i t YrL+' '•� .. .. <br /> • • `Y`L�{@��w''' <br /> b <br /> g :: V...: . ... . <br /> r.�ass <br /> .,,.....�. ..�� . :�� ..�......I -.,..... .. .... <br /> • <br /> ' PUFF-!C.}1Fld . <br /> HE i�iK p4V�i1a <br /> ERpNMENTAL <br /> j... ^ �.4.. ....i...... .. , <br /> V <br /> ........w... ..3_. ..I... .. .. ...>. .. .. <br /> : <br /> n ' <br /> - � °3r1vA <br /> FOR OEPNITMENT VSE ONLY <br /> IIZ67AI <br /> AMICATION ACCEPTED BY, DATE: AREA:��iJ ^tom <br /> TANK,PIT OR BUMP INSKZTKHA BY DATE I 1 FINAL INSPECTION BY 1/ . Tyj'/O•'r=-L/ OAT Ems/ <br /> ADDITIONAL COMMENi9: <br /> AOOOUNTIWj ONLY. AIOI FAC/ ::::L D <br /> NE CODE FEE INFO AMOUNT ROM ITER CIIEC AAH MCEVED BY PATE M/PESrt7T NtSU m IIlMVO10E/ I{ <br /> o /�o /7 «I <br /> / <br /> Pub.HeBHh Serv.-Errviro. 174(3/86) <br />