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APPLICATION FOR LIQUID WASTE PERMIT E SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES y ENVIRONMENTAL HEALTH DIVISION PA BOX 988, 904 EAST WEBER AVENUE, STOOMN, CA 95201980 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Com/Itts IB Trylkttt) _. �L APPLICATION 18 HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WOW DESCINDED. THIS APPLICATION 18 MME IN COMPLIANCE WITH CAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. PECODE FEE INFO AMOUNT REMITTED JOB AGGRESSION CRY LI /� C�A, ' LOT OIZE� ,A^,^P/N,,/^# - .'T 7 '7 OWNER'6 NAME 1W \ �' P,�Wi,r� ADDRESS PHONE �-Z2�3 CONTRACTOR (DK) V\,e-f ADDRESS UC► PHONE SUBCONTRACTOR ADORESB LRCS PRONE INVOICES TYPE OF SEPTIC WORK: NEW INSTALIATIGN REPAMADOITION❑ OODITRIECTmN❑ L� � Lilo, 5,,o0 � +IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FM OF BUILDING.) ►BIC TESTdI I 1 NOW MANY Q 03-\-800 AppESSSER INSTALLATION WILL SERVE: REBIOWIC >- COMMERCIAL 13 OTHFA ❑ NUMBER OF LIVING UMTS: l NUMSBR OF SEDROOMST- q NIINMBI OF BNPLOYAEES: I c CHARACTER OF SOIL TO A DEPTH OF 3 FEET.-Ind-Inn'-PITISUMP IL CHARACTER: 1 -DO iMWATERT DEPTH SEPTIC TANK101"SE TRAP 70—FO CAPACITY NO. COMPARTMENT �70—FO✓ I PKG TIRFATMFNi PLANT 11 INSTANCE TO NEAREST: WELL_ FOUNDATION PROPERTY LINE . UFT STATION ❑ size / �'�'' TYPE OF PUMP [_� SAND OIL SEPARATOR (ENCLOSED SYSTEM)qd LEACHING UNE NOIF� !i IFNOTH OF LINES t4 x O INSTANCE TO NEAREST: WELL,= FOUNDATION—PERTY UNE _ FILTER WD 13 WIDTH LENGTH DEPTH INSTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE MOUNDED ❑ WIDTH LENGTH DEPfN INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE SEEPAGE FITS DEPTH _ _ SIZE _ NUMBER-DISTANCEWELL FOUNDATION PROPERTY LINE 4-1 AO TO NNTEAREST: WELL PoUNOATN]NAREST: SUMPS WIDTH LENGTH_J.L�CL.._._ DEPrH__-,►►►SSS�`L PTgPERTY LINE _ DISPOSAL PONDS ❑ WIOTN LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERLY UNE 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND RULLN (1. V AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTINEB THE FOLLONANG: *I CERTIFYTHAT IN THE KFkrORMANCE OF THE WORK FOR WHICH THIN PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRNO OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIONLAWS CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPEOTIONs. COMPLETE DRAWING BELOW.) -O.f 'n _ SIGNED TITLE! m PLOT PLAN (DRAW TO SCALEI SCALE • IP 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE Of THE PROPERTY, WITH DIMENSIONS AND NORTH DIRECTION. EXPANC40N OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OP ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON 1 Lo INCLUDING COVERED AREAS SUCH A8 PATIOS, DRIVEWAYS, AND WA K8. THE PROPERTY OR MJOINMIO PROPERTY. V" r�/�lYfll� U� W ,a APPLICATION ACCEPTED BY_ TANK, FIT OR SUMP INSPECTION B' ADDITIONALCOMMENTs: F L FOR DEPARTMENT USE ONLY DATE I I FINAL INSPECTION 161 AREA: 0 11 p .DATE /0 V I / / ACCOUNTING ONLY: AUDI FAC) _. �L PECODE FEE INFO AMOUNT REMITTED CHECKS ASH FIEC19VED BY DATE SR I PBEWT NUMBER INVOICES o L� � Lilo, 5,,o0 � o 172 Q 03-\-800 r�/�lYfll� U� W ,a 0(.1 2 71996 IVN� �1TI .. :;... •... 4 i 1'Y IIJ� I ..:. .. —+' 4vil-1\7'l l � -: d I I'S rIL I,, APPLICATION ACCEPTED BY_ TANK, FIT OR SUMP INSPECTION B' ADDITIONALCOMMENTs: F L FOR DEPARTMENT USE ONLY DATE I I FINAL INSPECTION 161 AREA: 0 11 p .DATE /0 V I / / ACCOUNTING ONLY: AUDI FAC) PECODE FEE INFO AMOUNT REMITTED CHECKS ASH FIEC19VED BY DATE SR I PBEWT NUMBER INVOICES o -w-157 o 172 Q 03-\-800