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Ltv APPLICATION FOR LIOUID WASTE PERMIT SAN-JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX MSI 904 EAST WEBER AVEN JE,STOCIRON,CA SIMM-388 12091488-3420 NOW-REFUNDABLE FERMTT EXPIRES 1 YEAR FROM DATE ISSUED Z05 _ Mmaipl.Ts M TTi WWW vJ G APPLICATION S WFEBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO C0146TRIICT ANDrOR INSTALL THE WOW DESCIISM.THIS WITH APPUCAMN IE MADE IN COMR%ANCE SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110-3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PU KX HEALTH SERWCEB,WYMNMENTAL HEALTH OrVrWJN. 306 ADORESSIOR APNT Von 11{!� CITY F-SGOIa lI _pL.O�T SIZE��f�"�. OWNER'S NAME f ACORES' c PH01M coHTRACToR, r,j,(41`uU et ADDRESS / 15' (a ' Od�"awp _PHONR35-- SUS CONTRACTOR ADORES$ L1C. PLIGHT TYPE OF SEPTIC WORKi NEW INSTALLATION REPAARIADDRMN❑ DSSTRUCTOM❑ IND SEPTIC SYSTEM PEFOArTTED F PUBLIC SEWER SI AVAILABLE OAMTHIN 200 FEFT OF WMM*.OT SrIC TSSTbI(J NOW MANY APISePIhR� INSTALLATION WALL SERVE: FESI)ENCE ILK—coMMEICIAL❑ OTHER❑ C NRMER OF LJV1N0 UNITS:_NIMER OF SFJIIgOIM: 3 NUMSE%OF N.LOYSft: PAYM EN I CHARACTER OF SOIL TO A DEPTH OF T FEET:-y1� PITIOUMP 90414 CHARACTER: BL WATER TAE MPTTt RECEIVED SEPLTC 7ANKAOIEASI TRAP E�"MFO__ek- CAPACITY t(n P]E7 NO.COMIARI'MER$ ►KO TvKATIWIEIT PUNT❑ DISTANCE TO NSARSST: WELL f�_ FOUNDATION I OI P1RorETry UNE,,alf. I 1 .1/ UFT STATION❑ SIZE TYPE OF F'PMP SAND OS.SEPARATOR LENCLOSFO SY81011 LEACNNO LON Er No-A LENGTH OF LMS I 1 An.Jn..l�•I'J CO UN y y ��6 PRANCE TO N[MER:vveti 1 On PJUFIDATN)N ',n � y IIIC I Y RLTIM 660 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:VAIL _FOVNOATION '{VIRJ�✓ � ' MOUNDED ❑rWIDTH LENGTH DEPTH DISTAHCE TO WARIEST:WIML FOUNDATION PROPER"UPC SUPA09 FRSE� OEif E fH ERE 3� _NLIM -z—ONRANCE TO NEANf8T:YVELLj,M' FOUNDATgN AO• PROPERTY LAE o56 SLAIN ❑WIDTH LENGTH DEPTH DISTANCE TO NEAFEST:WELL_ FOUNDATION PROPERTY LAME DISPOSAL PONDS ❑WIOTN LENOTH DEPTH DISTANCE TO NEAREST:WF L --FOUNDATION PROPIRTYUNE I HERmY CERTIFY THAT[HAVE PREPARED TMS APPLICATION ANO THAT TEEWD WILL Of DONE IN ACCOAOA.ICE:NTH SMI JOAaM CONNTY 01pN1ANCE1 AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAW JOAOVIN COUNTY.HOME OWNER OR LICENWkl AGENT'S SIGNATURE C EMIfEB THE P.ILLOWRNO:Y CERTIFY THAT IN THE PERFORMANCE OF THE WORN,FORYNSCH TMS PLRMlT 18 ISSUED,1$HALL NOT EMPLOY ANY PERSON M SUCH A MANNEN AS TO BECOME KALACT TO WOrAMAW8 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MIwQ ON StWCONTRACTI CI 01GNATURE CERT"S THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICTI THIS PEAAR IS MMJM,19KALL EMPLOY PERSONS KS.IECT 70 WOH(MAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPVCANT MUST CALL 24 HOURS IN ADVANCE FCAt ALL 1EG411ED C7IOW,IPWISCOMPLETE DRAWING SElOW. �•-- SIGNED X df�{�-✓ TITLE: OII 1-t VC 7.(- DATE: a o PLOT PLAN(DRAW TO SCALEI SCALE 'LS I,NAMES OF STREE76 OR ROADS NEAREST TO OR SOLMAINO TIE PROPERTY. S, LOCATION OF HOUSE KWAOE DIMVSK SYRFTM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DSECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTIHO AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WMTISN RADIU$OF ONE HUNOWD FMRV FT.ON INCLUDING COVERED AHEM SUCH AS PATIOS,DRIVEWAYS,AND WALX9. THE PROPERTY OR ADADRSHO PROPERTY. 'r. Ir CTIe►f c S Q� ........:......: 1600 40.. . .; . . �EkS ........<................ . . .. . . : . 3v :.. . . . .. ..... _.... ........ ..............:..... ....,....:.... ....s......,..............,................. .'_.....`.. 011 De 9R RSS ONLY 11W2-w0Jl ADPLICATIOH ACCEPT!�D BY ATE: •� AREA: r TAMC,RT OR SUM'l INSPECTION SY DAT! I 1 FINAL INSPECTION SYA, DATE S_ 17-rte/ ADDITFJNAL COMMENTS: ACCO. n%o ONLY: AID/ FAC. F�p�-canE FEE INFO AMOUNT REMITTED CFECNSICASH RECVVIP PY DATE M I PSIR9T MIIRINEI INYoN:S S van tl 71 a