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APPLICATION FOR LIOUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 (209) 466.3420 TV`� / N0"EFUNDASLE PERMIT EXPIRES I YEAR FROM DATE ISSUED WC plsu in TF*GwW APPLICATION IS HEREBY MADE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDAR INSTALL THE WORN DESCRIBED, THIS A F ICATION IN MAI IN LOMRIANLE WITH SAN JOAOINN COUNTY DEVELOPMENT TITLE, CHAPTER 91110.3 AND THE XTANDAROB OF SAN JoA.DU1N COUNTY RJSUC HEALTH SERVICES, 9AIRONNF L HEALTH DIVISION. JOB ADDIESSIDP OWNER'S NAME SUB CONTRACTOR—'& /%J ADDRESS LIC/ PIIONE TYK OF SEPTIC WOAN_ NEW INSTALLATION ❑ PIPANVADDITION DESTRUCTION ❑ ONO SEPTIC SYSTEM PERMITTED.F PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF WILDING.) KISC TOTISI l ] HON ALANT APPSwSPn S� INSTALLATION WILL SeFVE: RESIDENCE I r COMMERCIAL 13 OTHER 11NU MSgt OF UVINO UNITS:/NIS.IS[R DF SfD11UOM8: NUMISR OF DAVLOY !� T CHAPIACTER OF SOIL TO A DEPTH OF 3 FEET: RTJauMP EON cHAAAc LEN: /L � WATER TABLE E DFPfH SEPTIC TMIROIIEAR TRAP /�0 TYPUMM �. � )�A/CP� CAPACITY W. NO. COMPARTMENTS — PROUNE— IEE LCL• PRO TREATMENT PLANT ❑ DISTANCS TO NEAPfaT: WELL L/C' FOUNDATION I'RDPERTY UNE IEE STATION ❑ �SIZE TYFF OF PUMP SAND OIL SEPARATOR (ENCLOSED SYSTEMI _ LEACHIM UNE y+ NO. A LENGTH OF LINES' DISTANCE TO NEAPEST:.I6f I FO INDATION PROPERTY UNE FILTER SED ❑WIDTH LENOTH DEPTH DISTANCE M NEAREST: WELLFOUNDATION PROPERTYLIE MOUNDED 13WDTH LENGTH DEPTH DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE S@AGE RTS ❑ OEM. SIZE _ NUMBER DISTANCF TO NEAREST: WELLFOUNDATION PROPERTY UNE M SUPS ❑ WRATH LENGTH__DEPTH DISTANCE TO NEAREST: WIELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑ WIDTH LENGTH _ DEPTH DISTANCE TO NEARENT: WELL _ FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS ARRJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN MAOUN COUNTY OROINANCEE AND STATE LAWS. AND MULES AND REGULATION6 OF THE SAN JOAOUN COUNTY. HOME OWNER OR L^ENSED AGENT'S SIGNATURE CEAI IFIES THE FOLLOVANM 'I CERTIFYTHAT M TIE PDEORAANCA OF THE WORK FOR WINCH THIS PERMIT IB ISSUED, 1 SHALL NOT ELMIOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUWLCT TO WYIRUAAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HNfNO OR -U NTRACTINO SIGNATURE CERTIFIES THE FOLLOWINO: '1 CFFITIFY THAT IN THE PERFORMANCE OF THE WORK FOP. WHICH THIS PERMIT IS ISSUED. 1 SHALL Ei.IROY PERSONS BL CT TD WORKMAN'S CCONIPENSAT ION LAWS OF CALIFORNA.' TNS APPLICANT M1117 CALL 24 HOW IN ADVANCE Mt ALLLLL/L PEOU/Rm INSPECTIONS, COMPLETE DRAWING BELOW. SIG NE x'/ /. C7/J9 J TITLE: YJ/^ >�l E�R DATE- 7 ATEO '1PLOT PLAN IUUW�TO WALV SCALE I, 1. NAMES OF STREETS OR ROADS NEAREST TO OR 60UNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BY UM OR PROPOSED 2. OUTLINE Of THE PROPERTY, WITH DIMENSIONS AND NORTH DIRECTION. EXPMS N OF SEWAGE DISPOSAL SYSTEM, O. DNAENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUPES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. � FOR DEPAMTIMFNT WE ONLY 4� APPLICATION ACCEPTED Br C LTJ T/1�1 GATE: AREA: 0370 TAAK, PR OR SUMP INS'JECTION Br ' DATE I I FINAL INSPECTION BY CATS I N ADDITIONAL COMMFNTS: ACCOUI(TI',NO ONLY: MDI FACI K CODE FEE INFO AMOUNT REMrrMD CinCN AJH RECEIVED BY DATE M I PERSTT NUMB, INVOICE0 Z i 0 I fL+1 S X40 wEL< ('k55?0'n�95P3� :!�-' . j�DLI,SE a .0 -1996 ... .. .. ..... r ... ..: :.. LFR H LINES A a- -'10'BFopeo I � FOR DEPAMTIMFNT WE ONLY 4� APPLICATION ACCEPTED Br C LTJ T/1�1 GATE: AREA: 0370 TAAK, PR OR SUMP INS'JECTION Br ' DATE I I FINAL INSPECTION BY CATS I N ADDITIONAL COMMFNTS: ACCOUI(TI',NO ONLY: MDI FACI K CODE FEE INFO AMOUNT REMrrMD CinCN AJH RECEIVED BY DATE M I PERSTT NUMB, INVOICE0 Z i 0 I fL+1 S X40 �3D(vD ('k55?0'n�95P3� :!�-'