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l 2 APPLICATION FOR LIaUID WASTE PERMIT RECErv�SCENE PAYMENT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 OCT Z 2 2000 (209)468-3420 SPUBLICAN JOAPL:,N NTA'ry SCOUNTY . NON•REFURUABLE PERMIT EXPIRES YEAR FROM GAT ENVIRONvF ISSUED MENT4, ERVICES ,;=gLTN bIVIS�Of; Icemplate IN TrIPAa111) APPLICATION hl HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A FERMrr TO CONBTRUCt ANDMFL INSTALL THE VMAK DESCMKD. THIS APPLICATION IN MADE IN COMPLIANCE WITH SMI JOAQUIN COURRY DEVELOPMENT TITLE.CH�P/ATEAi R t1-1� �T1y10.3 AND THEErIANDARDS OF SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES.VIVIRDNIM NTAL HEALTH DMWN. DORE JOB ASB1OR MINNII tt IZ AVC �—02 �, l A Z4 7- � CITY y �//C f P&^ _LOT&2E �5;p : ' OWNER'I NAME ]'�f"f 1C ] IlA IZR(� AODIFESS 7�r Al' tel f V A PHONE_ jI!��" •�� CONTRACTOR I!(fl C17_r--SA FY ADDRESS _ ),+.y 9 L�` Q LIC/ PHONE I if SUB CONTRACTOR ADORES. � r`Ly c^�. � /•I'�y I UC/moi^SNE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ PLEPASUADtIT1ON ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PER LAMED IF PUBIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILOING.3 POW TESTI+11 I WOW MANY r 4 ASN±-AA r r INSTALLATION WILL S9NE REEIIOEHCE❑ COMMERCIAL ❑ OTHER ❑ S NUMBS 1 OF WINO UMTS: NUMLIR OF BEDROOMS: NISYTrEEI Of EMPLOYEES: CHARACTER OF BOB.TO A DEPTH OF G FEET:_ PTISUMP SOIL CHARACTER: WATER TABLE DEPTIL— SEPTIC TMEKIOIEABE TRAP ❑TYPEJMF9 CAPACITY NO.COMPARTA* tS ma TREATMENr PLANT❑ DISTANCE TO NEAAWT: WELL FOUNDATION PROPERTY LIVE LIFT STATION❑ SIZE TYPE GF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING LIVE ❑ NO.•LENGTH OF LINM INSTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE PRLT01 BED ❑WM714 LENGTH_ DEPFH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - MOUNDED ❑WIDTH LENGTH DEPFH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UWE '' k i SESAGE#TS ❑DEPTH WE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIVE SUMPS ❑VVIOTH LvmTH -----DEPTH DISTANCE TO NEAREST:WELL ^FOUNDATION PROPERTY LINE } DISPOM PONDS ❑WIDTH LENGTH .DEPTH DISTANCE TO NEAREST:WELL—FOUNDATION PROPERTY Lox 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAs THE WORK WILL BE DONE IN ACCORDANCE WITH JAN JOAOUIN COUNTY OPIMANCEI AND STATE LAWS,AND FILMES AND REGULATIDNI OF THE IRAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'/BIONATURE CERTIFIES THE FOLLWY MVO:11 COMFY THAT INTHEPERFORMEANCE OF THE WORK FOR WHICH IWO PERMIT 12 ISSTIED,I @MALL NOT ELEGY ANY PERSON IN SUCH A MANNER A/TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CMI OW".' CONTRACTOR'S HMO OR BUB-CONFRACTiNo CERTIFIES LLOWING:'1 CERTIFY THAT M THE PE VOWANCE OF THE WORK P05A WHICH THIS PSWIT 11 ISSM,1$HALL EMPLOY PERSONS SVBJECr TO WORKMAN'S COZ:LAl /OFINIA.' T/11 APPLICANT MUST CALL SM NOESIS IN ADVANCE FO11 MS REG1J•im IN/1'ECTIONS. COIAPIl:TE DRAWING B79 ELOW SIGNED X TITLE: A!Z,4� i DATE: 1 2J E]]� 7/ PLOT DRAW TO ICALEI SCALE Xeo 5t 14-C F 'fe 1. NAMES OF STREETS ON ROADS NEAREST TO OR 801 PROPERTY. 4. LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSFfMS, `C 7. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, i. LOCATION Of WELLS WITHIN R AM8 OF ONE HUNDRED FIFTY FT.ON BNCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPOFTY. lt, o .. .. h PnR . .P (11 SRR i�� ... �iUX7 , .jw � 00 7, Alone PNS L to F 9 : ........... .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: EA:__L :_ TANK,PIT OR SUMP INW-V ION BY DATE 1 1 FINAL INSPECTION BY ATE•�asf !A!Q� t ADDITIONAL COMMENTS: �q'` ACCOWTIFAC ONLY: AID& FACT PE CODE FIE INFO AMOUNT TAMITED CHIC ASH Finav D BY I DATE NRR!PEW"NU MB@t INVOICE 0 Put,Health Sere.•Ernriro,174(3)98)