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APFUCATIOA FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468.3420 NOIt"FURDADEE F'ERINIT EkMAES 1 YEAR FROM DATE ISSUED IE:FUFMIS Is TrwilmW APPECATON IS HEREBY MADE TO THE SAN JOADIIN COUNTY FOR A PEPMTT TO CONSTRICT AN IMM INSTALL THE WAORFL DESCRIBED. THIS APPUCATMN R MADE IN K'OMRJAN!F WITH SAN JOB ADD JOA ADD COUNTY IEWEROPSFNT TALE.C`NAPF[/RJ 8-11110.3 AND THE/SJTANDARDS OF . AORAN COUNTY PUBLIC HEALTH OUNICES.ENAAD- ENTAL HEALTH DIVISION. RESS/pI AFfH 7U9�J E f4�/l`/G�• ACYL CITY M [oT SREa?14 OWNER'S NNUE •L1•tJl �.r)�/CIL-'.— ��+�.� ADDREeS�J„� _PHONE_�J I AJGsz� cDNrHAcron ;a/ l,n/, Cc�fi.s AooREBe�ft143 LJa,(tc %Oi1C. LU.C. LICr S- E 0 PHONE FUO CONTRACTOR ADCWWGS lKf PHONE TYPE OF SETTIG WORN- NEW INSTALLATION❑ REPAIMAOOITION DBETRUCTIDN❑ IND SEPTIC SYSTEM PEPPAMED F WOUC SEWER IB AVAKABLE WTTNIN ZOO FEET OF BIFILDINO.I PqC TLTNI 1 I HJW MANY INSTALLATION H+rSwSPe P_ INSTALLATION WILL ER L SVE_ I RESIDENCE O COMMERCIAL❑ OTHER❑ WARREN OF LINO UMTS: I NLRN\ER OF swwoIW:r_NLIMSEH OF EMTLnTm: CHARACTER OF SOS.TO A DEPTH OFFp3I FEET:. RTISVMP SOIL CHARACTER: WATFA TABLE DEPTH_ SKIM TANKRI I ASS TRAP ED TYPE/Mo CAPACITY NO.COMPARTIAENTB PLG TREATMENT PLANT❑ VMTM/CE TO NEAREAT: WELL FOUNDATION PROPERTY UNE UFT STATION L BDE TYPE'IF PUMP T"�"NO OIL SEPARATOR ENCLOSED SYSTEM) _ LIACHING UNE a NO.A LENGTH OF LREB—I- +) L1y Lv�A" I`O DISTAHCE TO NFAFEST:WELL GL.' T FOUNDA7—_ PROPERTY LINF, FILTER BED CI WIDTH LEMTH_ DEPTH OWTANCE TO NEAREST:WEU. FOUNDATION PROPERTY UNE FEORS/OEO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFo,)NDATgN ROFERry UNE SEEPAGE TS amPT" S I S¢E_'sb I_-MWER�_DISTAME TO FEA EST:WELL (Jr-' IOUNDATION "IS PROPERTY timcUW iv,t I SIVA ❑worH LENGTH_—DmrH INSTANCE TO NEAREST:WELL _FOVNDATION PDtERTY UNE O DISPOSAL FORDS ❑WIDTH LENGTH -DEPTH DISTANCE TO NEAREST:WFLL--FOUNDATON P7IDPERrY LINE —Ll 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPMATION AND THAT THE WORK YPLL BE DONE IN ACCOP DANCE WITH OAN JOADLISI COUNTY ORDINANCES AND STATE LAWS,AND IIVIEB AND REOIRATpNB OF THE BAN JOAOUNCO VARY.HOME OVVNER OR LICENSED AGENT'S NONAT%W CERTIFES THE FOLLOWING:7 CER7IFYTHAT IN THE PEIEOIRIAfK!OF TRENOfR FORNTKN THIS PlRAO7 IS ISSUED,1 WALL NOT EMPLOY ANY PERSON M SUCH A MISER AS TO BECOME eUBJECT TO WOMMAN I C01AFfNOATION LAWS OF CALA'ORSA.'CONTRACTOR'S HIRING OR M SSB-COMTRACTNO SKINATUNE CERTIFIES THE FOLLOWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WORK POP NMICN TRSS PERMIT 19 I58l1ED.1 SHALL EMR.OY PERSONS WILIECT TO l 1 Vftw ARTS COMPENSATION LAWS OF CALIPORNUI' THE AFPxILM MIST CALL 24 HILUS N ADVANCE FOR ALL.R[GVNfD INSPSFIOIIS. COMPLETE O RAWNG BELOW. � _ LL� -per BOWED%_ TRLE:_�/yy]yfOK DATE: 7��/"T Ci 1 PLOT RAN WRAW TO SCALE).SCALE 1.NAMES OF STREETS OR ROADS NEAEIFST TO OR BOUNDING THE PROPERTY, �4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PHOPOBED 2. DUTII,E OF THE RIOPERTY,WITH DIMENSIONS AND NORTH DIRECTION. E"ANBgN Of SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTUNES AND LOCATION OF ALL MGTING AND PROPOSED STRUCTLRNE EC, 6.LOCATION OF WELLS WITHIN RADIUS OF OHUNDiOD RFTY FT.ON NCLUDINO COVERED AREAS OUCH AO PATIOS.MVEWAYS,ASA WALK& THE ApPERTY OR AD-JOINING PROPERTY. .. .:...........�...... ...:......:...........:......e.... .... ....... ... .. `.................... i .. PAYM... _ ............•s... .. ..:......:... . ► :.....:.................:.... .......... . . .....'--'PUfILIY`'?I&'S.SH 5>..fi '' !. _.... .tl.....e........ - ..... .... : hli'I'4 GEY45 •aJ . pphINIEHTALt1E. .. I .> . W. LY .q .. :...... . ....... .:............. _�rlv FOR DIPAATMENT INE ONLY y/1 APPLICATION ACCEPTED BY DATE; AREA. �.J,I—!. �/� TANK,PIT OR BUMP NSPECTOII BY DATE / I FINAL INSPECTION SY DATES/ ^/- AOPTONAL COMNEH!6: ^� --TI-ONLY: AIOf FAC/ D 1-�" >4 CDD' FEL INFO AMOUNT PAM ITED CIIEC ASH RIECETVSD ST DATE LIR I1`11"T INWOICE I o a/�o /� GD 7a� • Pub,Health Sc,.-ETIYRD.174(3146)