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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)488-3420 ■OM•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICo"Nift in TPMreul APRFCATION IB HEREBY MADE TO TTE BAN JOAOUM COUNTY FOR A PIR MIT TO CONSTRUCTµOAR INSTALL 1 HE WORK OESC IBBED.THIS APPLICATION 1/MADE IN COMPJANCE MTH SAN JOAQUIN COUNTY DEVH.OFMENT TITLE,CHAPTER 8.1110.3 AND THE STAN DARD@ OF SANJOAQUINJ{OO�AQUIN COUNTY PUBLIC HEALTH SERVICEIL ENVBIONMENTAL HEALTH D4%MPON. JOB AODM68MR AJNII (/ -52I,�� I e A _ _r 1 1 CITY r// �4f -- -- LOT BIZF OWPER'S NAME E� PL I�iC//4 �,(.�.lC/la�!_ se '2( e) '"7 /l/'��/Y RHONE CONTRACTOR .P l.:. J�G1� ADDRESS SINS CONTRACTOR ADOM" UCP PHONE TYPE OF SEPTIC WOR(: NEW INSTALLATION❑ BfTANJ"MTIONX OESTRUONON❑ INO SEPTIc SYSTEM pEEeARTEo M PUBLIC SEWER M AVAILABLE WRMN 200 FEET OF SUKDRNG.) PSIRC TESTI.)I I NOW MAFIY AFPSaASSR S INSTALLATION WILLSBNG RESIDEME 7 COMMERCIAL❑ OTHFH❑ NUMBER OF LA/MO UMTS: NMMBLR OF OEM NUNLIEEI OF E MPIDYMS: CHARACTER OF SOIL TOA DEPTH OF 7 ISLET A PIT/BUMP BOIL CNA/IACTER: WATER TABU DEPTH SETHC TANKIO E.YE TMP ❑TYPE/MFGCAPACHY NO.COMPARTIAENTB I►KO TREATMENT PLANT❑ WTANCE TO RFAREBT: WELL FOUNDATION PROPERTY LINE— No INEN❑ SIZE TYPE OF PIMP SAND 00 SEPARATOR(ENCLOSED SYSTRAI I/vr�a7J��SrU,= /� /h r — IEACNRO NO,t LENGTH OF LINES CQ �C/(/ DISTANCE TO NEAREST'WELL , OATKIN � MIOPERfY LINE FILTER SED ❑WRITH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDm ❑T��R LL MOTH LENGTH DEPTH DISTANCE TO NEAREST:WEFOUNDATION PROPERTY LINE ■MPAOE P 1-A TB DEPTH BRE NUMBER DISTANCE TO MEANEST:WELLFOUNOATIC/1 PROPERTY UNE SUMpB ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELT FOUNDATION PROPERTY UK 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE NTTH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAW$.AND Ri1LES AND IEAULAT10148 OF THE SAN JOAQUIN COUNTY.NOME OWNER ORLICUMD AGENT'S SIGNATURE CERTRIEBTHE FOLIDWSM:1 CERTIFYTHAT M THE PERFORMANCE OF THE WORK"WHICH TMS PERMIT M IBMIE D,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO SECOME SUBJECT TO WORRM.WS COMPE NSATgN LAW'S OF CAIIRDWJIA.' CONTRACTOR'S HBSNO OR SU"ONTRACTOM SIGNATURE CEIITfrEB THE FOLLDWRNO,7 CERTIFY THAT IN THE PERFORMANCE OF THE W019K FOR WHICH THIS FERRET IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOPS(MAN'S COIJPENtATgN UNNS OF CAUN'ORNI TK IVR1CANi MUST CAL(,2s IOVRi IN ADVANCEREQUIBUED /4 COMPLETE PLOT RAN CORRAW 10 SCALE;WALE_ 1.NAMES OP EFFIMS OR ROADS MANEGE TO OR BO NDINO THE PROPERTY. 4-LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OPR PROPOSED 2.OUTUNE OF THE FRIOPERTY,WITH OLMENSIONS AND NORTH DIFECTION. EXPANSION OF SELVAGE DISPOSAL SYSTEMB. 7.DIMENSIONED OUTUNN AND UDCATRFN OF ALL EXISTING AND PROPOSED STRL/CTLNEB, 6.LOCATION OF WELLS WITHIN RADKJS OF ONE HUNCFEO FIFTY FT.ON (Jy BICUIDDA COVETED MEA/OWN M PATIOS,DRVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY- 7. ..... _ .. ..... .. _1.1....... . 1'7—. iTj;./,c t' i. _.._. .... ..:,.. .. 1...:............ .. .. .._....... . .... VW: �R �C .V�. .,.......... .' f}} ......... (S . : . _ e v. . .....:......,..... .. . ..........E.,\ .�'............ .. ...... . .......... :... .....'.. . ......__...... .. :... L7R:�o. .... . .. .;... ' ..... .... ,............ . 4. . ,......,. +....... ENT a _............. ., . 'q-t. :..RSC IV�[3.. . e......... :...... . :.. .:... �;...... :'D'EC ...... u ��. ...... ] .. �n�:. ..:.. ............. .... . <........ ..—....� - — C�' R tElEi€ '.liEJzlA iilMSIUH ...... .. ... .... % y` 14. FOR oLEMTMENT USE ONLY ^/� 7 AFRCATION ACCEPTED BY ASA /��JJ T .PIT OR BUMP Mem ql BY t� DATE 1 l FINAL INSPECTION BY DATE 1!_,/Z, E ADOITIONAI.COMMENTS: 11-2.1-LOGO I N61 l.'iCZRrBQ d �� p E Rlu o ADcavNRNo ONLY: ADI FAC. Ey' FEEINFO AMOUNT RBD ITTD CRIED ASN RF10EVm SY DATE SR L It op Pub.Health Se,--EmVo.174(3/96)