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APPLICATION FOR LIQUID WASTE PERMIT 3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 NI)WAFFUNDABLE_PERNItT EXPIRES 1 YEAR FROM DATE ISSUED fCample.IR TripAcate) APPLICATIGN IB HEREBY MADE TO THE BAN JOADUIH COUNTY FOR A PERMIT TO CONSTRUCT ANONR INSTALL THE WORK DEWPSBED. THM APPLICATION If MADE IN COMPLIANCE WITH SAN JOAOUIN COUH7Y DEVELOPMENT TTTP/7.E/,CHAPTER 9-11111j0.3 ANo THE YTANMM DDS OF N AOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVf10MJFNTAL HEALTH D1Np 6N JOB ADDRESSNOR APNF / `T��'Gl //S N� CITY G _- LOT SVF /�L 11 OWNER'S NAME fiyC+� ( �w�.N�i AGGRESS / /� PHONE��.`� 7 CONTRACTOR ��`1Y <-'f�lG�/T� AGGRESS UC4?r�tJ3 C/�+ PHONES, SUIS CONTRACTOR ADDRESS LIC, PHONE`r TYPE O'SEPTIC WORI(: NEW INSTALLATION REPANUADDITION❑ OFSTRlMT10M❑ INE)SEUTTO SYSTEM PERI MTTED lF PUBLIC SEWER IS AVARASLE NRTHIH 200 FEET OF SUILVANS.I P9lC TSSTIsl{1 NOW MANY ,N,.�,yL APPSOPSOw F INSTALLATION WILL E SERVE! AFFIMNCE❑ COMMEHCIAL 74 OTHER❑ RUNNER OF LINO LFMTS: NUMBER OF BEDROOMS:I, -- NUSARG R of HNPLOYEEE: CHAWIC7FR OF SOIL To A DEPTH OF 3 FEET: �,j/ /PITfSLW SOIL CHARACTER. / WATER TABLE DEPTH '�� f SEPTIC TAFaUORTRAPEASE T ► ❑rvmMFG '^Tl�/ CAPACITY— NO.COMPARTMENTS PO TREATMBTT PLANT❑ INSTANCE TO NEAREST: �WEILT � FOUNDATION �Q PROPERTY UNE UFT STATION 0 SUE TYPE OF P NW BANE)OIL SEPAAATOR!ENCLOSED SYSTEM) LEACIaNG UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL �J�� FOgU UNOATN PROPERTY NE FILTER SED M MUTH� LENGTH/, DEPTH DIST/VICE i0 NEARE ST!N.ELt�Xu�'_l �FOVNDAT10Nl�PROPERTY LINE MOUNDED ❑,MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I�I� SEEPAGE RTS ❑DEFY" SUE NUMBER DISTANCE TO NEAREST:WELL FOUNDAT10H PROPERTY LINE y SUMPS ❑WIDTH LENWH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION RVPETITY UNE DISPOSAL PONDS ❑WNRH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYLINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WHH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES � I AIFD REOVlATl0116 O}T/IE BAN JOAONIN COU1rTY.HOME OW NEROR LICENSED AGENT'S BOHATUPE CERTIFIES THE FOLLdMFIQ:'ICERDFYTHAT INTNE PCROI'MANC4OP THE WDRK FOH WNCH THIS PERMIT IS loomm.1 SHALL NOT EM FLOP ANY PEROON IN SUCH A MANNER AS 10 BECOME BUSJECT TO WOFKMAFrB COMPENSATION LAN70F CALIFORNIA.- CONTRACTOR'S NMNG OR BUB-CONTMCTDNO SIGNATURE CERMPEO THE FOLLOWING:'I CERTIFY THAT M THE PEWOMANCE OF THE WOFW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA-' THE APPUCANT MUST CML M NOV"IN ADVANCE FOR ALL ANGUISHED INSPECTIONS. COMPLETE ORAWING BELOW. /. BONED%_�--� 1� _ Ttt1�: 1 DATE: PLOT PLAN WMW TO OCALEI SCALE IO /J I. NAMES OF STREETS OR ROADS NEAREST TO OR BOIINOINO THE PROPERTY. L.LOCATION OF HOUSE SEWAOE DIMOSAL SYSTEM OR PROPOSED I 1 2, OVTLJW OF THE PROPERTY,WITH DIMENSIONS ANL,NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, OWENIPIOMED ODUTLUNES AND LOCATION OF ALL EXISTING AND PROPOSED 6TRUCTUREP, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FNTY FT.ON 6.1CLUDINO COVERED AREAS SUCH AS PATIOS.DI IVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPEIITY. +/! .. .. .. .......... ... • N9 L j . .... . .............. 1 J /G l _ _...i......;...................... ..:.._.... ...... . .. ....... ....... ..... ........:.. �Ad '.. .JUN 2 9 .4998 a .. ... .....: ... .............. ... . .. .°....: .. . ....... ... ..... ... :. . . ... .. N�JOHQUIN�GGLfN'fY I,IG*1E�4�TH S�RVIcEa,. IftQNMEI.ITAL NA LT H 04V15 FOR DEPARTMENT USE ONLY APRXA710M ACCEPTED BY �• .�/)1��-L— —� __ DATE: AREA; TAN(,PIT OR SUMP INSPECTION BY DATE ( ! FBAL INSPECTION BY - _ DATE ! r U 1 R ADDITpNAL COMMENTS: 1 ACCOU ETrNO ONLY: AEO.F PL CODE FEE INFO ASNOLWT RB,S ITED CINEC ASH RECEIVED BY DATE M IFRESNT NUMER INVOICE! S�pb(�Olo-I, Pub,HBaM Serv.-Errviro.174(3/96)