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APPLICATION FOR LIQUID ASTF PERMIT <br />SAN'JOAQUIN COUNTY PUB LIMEACiTif SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />j P.O. BOX 388, 446 N. SAN JOAQUIN ST. STOCKTON, CA 96201.0386 <br />1208) 488.3420 <br />VON -REFUNDABLE RMI I YEAH FROM <br />IC=WktP in TrgRatE) <br />APPLICATION IS HERESY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCROSED. THIS APPLICATION IS MADE IN COMPLIANCE WIP11 SAN <br />JOADUN COUNTY DEVELOPMENT TILE, CHAPTER 9100.3 AND THE STANDARDS OF SAN JOADUIN COUNTY PUSUC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />f-7 — —. i W - <br />JOS ADDRESW OR <br />LAT SLg1_-" <br />OWNER'S NAME_W / ADDRESS PRIONS, <br />CONTRACTORADDRESS UCI FNOHE <br />SUS ADORERS CONTRACTOR A, L , F//L� .�,e ��11� <br />TYPE OF SEPTIC WORK: NEW INSTALLATION JI I@ANUAL1orT10N ❑ DasTRUCTION ❑ <br />WSEPTIC SYSTEM PERMITTED IF PULNUC SEWER T <br />IS AVAILA&l WHIN 200 FEET OF BUSDING.V PYIC TBSTRM 1 1 NOW MANY_ <br />ApUwlbw f <br />INPTALLATION WRL SOWS: MSOENCE COMMERCIAL 13 OTHER 13 <br />NUMBER OF UVWM UNITS: I NLJRUe1 OF LIEORoOMs: _ MUMMER OF EMPLOYEES: <br />CHARACTER OF SOIL TO A OEPTX OF J FEE'j:_ PIT/Sump SOIL CHARACTER: Q L/' 1J _WATER TABLE DEPTH <br />SEPTIC TANK/OIIEASE TRAP ❑ T'PEn.IFG pL�J_ CAPACITY f(p 00 MD, COMPARTMENTS <br />PRO TRFATM IWT PLANT ❑ DISTANCE TO NEAOMT: WELL. C.d)r[ ,t FOUNDATIONPROPERTY UNE P <br />LIFT STATION ❑ SIZE TYPE OF IA MP // SAN) OIL SEPARATOR (ENCLOSED SYBTEMI J <br />11ACplq UNE ❑ NO. B lENOTN OF LINES f'� CO Ci / DISTANICE TO NEARFBT: l MAIDATIgI�• PRDPFIRY LINE /d r , <br />PILTOI SED 13 WIDTH LENGTH__ DEPTH DISTANCE TO NEAREST: WELL FJUNDATION PROFERTY UNE <br />MOUNDED 0 W10TH LENGTH DFFTX DISTANCE TO NEAREST: WELLFOUk0ATgN PROPERTY UNE <br />SEWAGE PITS ❑ DEPTHSITE NUMB <br />ER DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UME <br />GLIMPS ❑ WIDTN��T` L84TH � DEPTH-4�aL DISTANCE TO NEARM: NIELL FOUNDATION_ PROPERTY UNE--,? ",7- r <br />DISPOSAL PONDS ❑ WIDTN LENGTH DFFFH DISTANCE TO NEAREST: VVELL__ FOUNDATION PROPERTY UNE ^` <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TE WORK WILL SE DOPE N ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES AND STATE LAWS, AND IS11.E8 l l� <br />AND IEOULATON9 OF THE SAN JOAOUN COUNTY. NOME OWNER ORUCENSM AGENT'S SPSNATU RE CERTIFIES THE FOI.LOWM:'I CERTIFY THAT NTE PEFWYEAICE OF THE WORK FOR WMCH <br />THIS PERMIT IB ISSUED, 1 SHALL NOT EMPLOY ANY PERSON N SUCH A MANNBT AS TO BECOME SUAIECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' CONTIIACTOWS HSENO ORI �) <br />SLB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWMNO: 'I CERTIFY THAT N THE PERFOPMANCE OF THE WORK POR WATCH THIS PERMIT 10 ISSUED, I SHALL EMPLOY PERSONS 9UISJECT TO <br />WORKMAN'O COMPENSATION LAWS OF CAUTORHA' THE APPLICANT MWT CALL b HOURS N ADVANCE PON ALL R�.E.O/.ILINN�s INM�EC�TH/INR. COMPLETE DRAWING BELOW. <br />SIGNED X TRIF.:-y,cL/��i�i. za- 1 (RATE: <br />RAT PLAN IORAW TO SCALEI SCAT L ' W <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPEM. WITH DNNER/BIOFIS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMMO MONED OVTUNFO AND LOCATION OP ALL EX18N10 AND PROPOSED STRUCTURES, S. LOCATION OF WETS WITHIN RADIUS OF ONE HU1O1m) FWEY FT. ON <br />INCLUDNO f11VFART Awc�A aY-u .a na�v.a ns �,....... ..... ..... ._ <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY DATE: <br />TANK, PT OR SUMP INSPECTION( BY {{ j 'f DATE I / FINAL INSPECTION <br />ADDTTONALCOMMEI/TB: T JL' ty h-) Lf,ll1 r�� TT 3 1ti Jn V k y' / 1 j16+jT <br />} <br />DATE <br />