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F APPLICATION FOR LIQUID WASTE PERMIT SAN'JOA(IUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 384 304 EAST WEBER AVENUE, STOCKfON, CA 952Q1 (2DO) 468.3420 NOR•Rff"DAaLE PERRRT EXPIRES 1 YEAR FROM RATE WHO lCoWlett In Tr"ute) APPLICATION IS)MrjjY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED. THIS APF�IAT1ON 16 MADE IN COMPIANCE YMTH SAN JOAQUIN COUNTY DEVELOPMENT TRLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERIACEs1.EEN��RiDNMENTAL NEALTN I)MWJN. ,POB AODIIESSAM APNI w• b CITY_ r,.-rlvrV �... _LOT 012E O• Clt OWNER'S NAME ��j� S,p 2 ADDRESS__• PHo►NE CONTRACTOR`Sb�. ADDREs>a_114�5•l t �� UCr 1 SUR CONTRACTOR AOOFIESB LIC#�_PHONE TYPE OF I0rM WORK: YEW RMTALLATIOII ❑ ROARIADDITION IR OIBTIRPQTION❑ NO SEPTIC SYSTEM PERMITTED IF PU9:1C SEWER IS AVAI,ABL.E WITHIN 200 FEET OF BUILDING.) FORD TUT10 I I NOW MANY AppE # INSTALLATION WILL tiRVti: RESIDENCE Ll COMMERCIAL id OTHER❑ NM#fl71 OF LIN RIO LININS: NIAYIIleI OF BEDRNOOMt: NIwRVI OF EMPLOYEEN: CHARACTER OF BOIL TO A DEPTH F]R�£T:�y91pL _PITISUMP SOIL CHARACTER: '� I pr WATER TMLE OEPTIJ � SkYTFO TANKIOIIEASE TRA► CAPACITY CZ IIrvPEnaFG� cc js�p �olc�w�� No.colupAmMENTa_ '�rr�{/MQ1 ►KG TREATMENT PLANT❑ d .NCE TO NE^P*9F: WELL L � FOUNDATION 100 PROPERTY LINE I GD UFT STATION❑ SITE TYPE OF N'VMP SAND 00. TOR!ENCLOSED 6YSTEMI LFACIINO UNI B NG.A LENGTH OF LINES— IIRQ, DISTANCE TO WARIEST:WELL 1,SU ' F'JUFDATT M All JCI PROPERTY LFNE r �= FILTRI IED ❑WIOTH LENGTHDEPTH 016TANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE Q. MOUNDw ❑WIDTH LENGTH DEPTH 016TAMP TO NEAIE41T:YVELL `POUNDATION PNDPERTY UNE C •@AGE•PITS ❑DEPTH SIZE -NUMBERS DISTANCE TO NEARE7T:VOI L FOUNDATION PROPERTY UNE !UMTS ❑%MDTH LENGTH DEPTH DISTANCE TO NEAPEIIT:WELL— --FOUNDATION PROPERTY LINE r DItPOSAL PONDS ❑NADTH LENGTH Ek�PTH DISTANCE TO NEAREST:WELL_ FOUNDATION PROPERTY LINE G I HEREBY CWTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TILE WORK WILL BE DONE W ACCOHDANCE rNITH IAN JOAGUIN COtwrORE)WMNCES AND STATE LAWS,AND RULE$ j AND RREGULATIONSOFTHE SAN JOAOVINCOUNTY.HOMEOWNER ORLICENBL7AGENT'tBRGNATURECERTIFIESTHE F'OLLOWMG:'10ERWYTHATINI,ITHE OfTHEWORKFORYVNICH THIS PFMIIT IS ISSUED,I SHAD.NOT EMPLOY ANY PERSON W SUCH A MANNER AS TO BECOME GUSACT TO VVO#VAMAMV COMPENSATION LAW@ OF CALIFORNIA." CONTRACTOR'S MING OR � SUB-CONTRACTING BIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT 14 THE PFRFORM}WCE OF THE WOl!a FOR VVISCH THIS PERMIT IS)"UED,1 SHALL FMPLOY PERSONS VJlSJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 34 HOULS IN ADVANCE P<'At ALL REGLIRAD IN4MTIONI. COMFLETIE DRAVANG(FLOW. r ATONED X Trc/f: rMrDATE DATE DATE S - 4- ;e PLOT PAN(DRAW TO SCALE]SCALE .10 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE ffROPERTY, 4. LOCATION OF HOUSE NWAGE DISPOSAL SYSTEM OR PhOPOWD 2. OUTLINE Of THE PROPERTY,WITH O AAENNONS AND NORTH DOWCTWN. EXPANOWN OF SEWAGE DISPOSAL SYSTRAS. 7. DIMENSIONED OUTLRIES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. 6. LOCATION OF WELLS RADN"OF ONE HUNDIED FIFTY FT,ON INCLUDING COVER®AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAULS, THE PROPERTY OR ADM PROPERTY, ) 46 ......q. •4•• ..i... ..... .. .. ..y... �.. •..P.... ..p. j ... T...o...... .p... .. v. ..4.. .... ...... qaY • r Q Ll .rp v �. RO Tl j. ;if .v 15 �G :r s TUN :. :............q......; .,......:.. E 1 .. .,y..........:........... . .. ..... .. .. .. . ...a... ... ' • . .. ...: .. - > ......:...... - : : : ...:....:. ..: :. �"� '... ........... . .. .:.....n .i .. �............ ........ .. ..�. - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTIED BY DATE: AREA:_ TANK,PIT OR SUIXP INSPECTION BY DATE I J FINAL INBPECTION SY -A•T�'_LI�_O ADORIONAL CCMMENT'S: T"' {' Ov ACCOUNTING ONLY: AIDE FACP !'E CODE MLWO AMOUNT RIMTTED HSC JCA RECg1lED MY DATE S11! T humuffim INVOICE# 0.v?0