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APPLICATION FOR LIOUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O.BOX 98%304 EAST WEBER AVENUE,STOCKTON,CA 95201368 (208) 489-3420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FRON DA[E ISSUED (GIR'ISES I6 TT4RpiBl APPLICATION N Wi HEtY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/d1 NSTALL THEW ORI(DEtCMH RED. TS APPLICATION K O!IN MACOMMIANCE IMM SAN JOAOUIN COUNTY MMOPMENT TITLE,CHAPTER 9-1110.3"AMNO THE OTANDAPIDS Elf SAN JOAQUIN COUNTY PUMJC HEALTH SERVICE!,ENVIRONMENTALHEALTH DRRM'JN. JOS ADDRESS=APNa 2a/J/ 4(J�7�iy X. "1 b -b CFTY��'.QI1�%2 _EDT6IEE'A-iC a OWNERYB HAMe�,lt/-I/0 EF. G°S�/ANtl ADORE33 Sa'/ G'.�il��i��.iJ_ !�� /1J.o.ArrL�..Q PHDHE_e CONTRACTOR ADORFSS LIC# ry PHONE r SIA CONTRACTORADDRESS- P TYPE OF SSTRC WORT; NEW INSTALLATION AWAR ADDITION ❑ DESTRUCTION 0 NO SEPTIC SYSTEM PeWF TEC)M PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUI DIM.1 PEW 716741 1 I HOTS MANY App•aSSen• INSTALLATION WILL■RIVE: RESIOENCF Int COMMERCIAL❑ OTHER❑ MUMHR OF LIVING UMTS:_'_ NUT. .OF SEDROOMS: "�'/ _ NUMBER OF SM M.OYEB: CHARACTER of BOIL TO A DEPTH OF J FE FT;�9Ai D-V—PR/SUMP 9011 CHARACTFR: WATER TABLE DEPTH siRIC 7ANR/gRFlMBE ERM ❑IYFE/MW_ / Fy.¢L� CAPACITY_ HAIL/-Q NO,COMPARTMENTS DL FIO TIREATMENT PLNlY 13 1116TANCE TO NEAREST: WELL FOUNDATION Fr PROPERTY LINE-212--= LLT STATION❑RSSIZE TYPE OF RIMA BAND OFL SEPARATOR(ENCLOSED SYSTEMIp T .s— LEACNMO UTE NO.6 LMNOTH OF LINES �–�tJ�T DISTANCE TO NEAREST:WELL /l� �F'JUNOATIONL3��FROFEFfTY FI S® ❑YNDTH LENGTH__ DEPTH DISTANCE TO NEARER:WELL .FOUNDATION PROFEIRY LNE v MOUNDED ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:VGELL ,FOUNDATION P74FUTTY LINE Q 6®AGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAllST:'AMILL _FOUNDATION pROPPJITY ISL O SUMPS ❑WIDTH LENOTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE V DISPOSAL POW" ❑WAMH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROIRERTY URNS 1 HELY CERTIFY THAT I HAVE PRPARED TR6S APPLICATION AND THAT THE WORE WALL BE DHOW N ACCORDANCE'A"SMI JOAQUIN,COUNTY ORMAMCEN AND STATE LAWS,AND RULES Q AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LIC ENSEll AGENT'S BIONATURECERTMRES THE fJµOlArOw I CERTIFY THAT N TIL FRl01MA)CE OP THEWOIRCFORWHICH THIS PENJIT N MUM.I SMAIA NOT EMPLOY ANY PERSON IN SUCH A MANNE11 At TO BECOME SUBJECT TO WOFAMAMS COMpENSATIOM LAWS OF CAL FOFINI CONETRACYOR't HIRING OR SL/6-CONTRACTM SIGNATURE CENTIPMB THE MUOWNG:1 CERTIFY THAT IN TIL PERFORMANCE OF THE MPOW FOR WHICH TMS PETERT It ISSUED,1 MSALL EMPLOY fERSONR SUSJECT TO WOFKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THIS APPLICANT MUST CALL N HOURS N AOVANCS MAR ALL 1011121.11011110 INBFlCT1OM6. COBML.ETE PRAY NO SBOW. SI3H[D lI Ail M TREE: Cry��/ DATE: 0 PLOT PLAN IOMW TO SCALEI SCALE -Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROpETTTY. 1. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2-OUTLINE OF THE PROPERTY.+NTH 04 ENSIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE OISP'OBAL SYSTEMS. J. OENED DUTUNES AHD LOCATION Of ALL EXIETIHG AND PRDPOBEO STTIUCTURES, S. LOCATION OF WELLS S WITM N RADIUS OF O!L NUFIOIEG PLTy FT.ON INNNSIO CLUOFRI COVERED MEAS SUCH AS PATIOS,OW.IEWAYB,ANO WALKS, THE PROPERTY OR ADJOINRM PROFpRY. .. : Jay- �W .. . . .'. i' k1 .. 2. :.... ... ............ i 4=4L. FOR OWARTMEMT USE ONLY OI APPLICATION ACCEPTED BY DATE: J I • AREA: A V TAMC,PTT OR 6{M,I INMSC710K SY bR7E__ 1 1 FINKFIWfC-1.NY GAT! ADDITIONAL COMMENTS: AN;COUNTNO ONLY: AUDI FACE �1TL FE COOS FEE INFO AMOUNT ARAITTm HEC SIC ABH RECHVFD BT DATEM I PERMIT RUIEIR FIVOFCF I '{ 4�JJ j er r 8's-1. z