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d APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCiCTON, CA 95202 <br />(209) 468-3420 <br />N•REFUNO LE PERMI PIREB I YEAR FROM DATE 11SUED <br />ICamplat. In TFlprmstal <br />APPUCATHM M ""Way MADE TO THE SAR JOAQUIN COUNTY FOR A PENWT TO CONSTRUCT ANOXR INSTALL THE WOR( SAI/ <br />DESCIOa EO. THIS APtUCATMN IE MADE IN COMPUANCE WrTN <br />JOAOUOI COUNTY O[VELOFMEM TrTLE CHAPTER &111 D.i AND THE STAND`A DS OF SARI JOADIUM COUNTY PUBLIC HEALTH SERVICES. ENIAPIDNMEWAL HEALTH DIVISION, <br />LOT SZ <br />`Z 57 PpNE�-5IL 3 <br />SUBCONTRACTOR <br />ADORERS LCI PIDNE <br />TYRE OF SEPTIC WORK: NEW INSTALLATION ❑ <br />RIEPMNADOITION DuTNUCHON ❑ <br />MO SEPTIC SYSTEM PEPIMIrTED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.. <br />P61C TESTbI 1 1 NOW MANY <br />AFPBeASER / <br />INSTALLATION WILL EEN VL RESIDENCE COMMERCIAL Q <br />OTHER ❑ <br />NUA01 OF LIVING UMTS: viumma;n OO�F[,.,Sra®R[?[oms. <br />NUMBER OF OIIRLOY`EDO: <br />CHARACTER OF SOIL TO A DEPTH OFT1--J3T FEE'11 <br />PITISUMP POW CHARACTER:: `ATEA TABLE DEPTH <br />/ <br />SEPTIC TANK/OREASIE TRAP LTYPEJAIFO <br />CAPACITY NO. COMPAIfTMEMB <br />PKO TREATMENT PLANT ❑ DISTANCE To NEAREST: WELL <br />UFT STATION ❑ SSIIZE TWE OFFLINK PUMP <br />FOUNDATION P OPE1Try ONE <br />SAND OR SEPARATOR BiNCLOSEO SYSTEMI <br />�_ <br />LFJIOISIYO f �' NO. a LENOTN OF LMEBQL—`Y(/ �, <br />DISTANCE TO NEAREST: : WELL FOUIOATR7N � PAOeERrY ONE S� / <br />RLTM NED ❑ WIDTH LENGTH <br />DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PIOPEM UNE <br />MOLMDED ❑ WIDTH LENGTH <br />DEPTH DISTANCE TO NEARE91 r WELL FOUNDATION PROPERTY UNE <br />^� r7 r <br />$MADE Mrs DEMH 7 C E ME 3� NVMSEP O� DISTANC( TO N., FOUNDATIONLei ! PgPERTY ON Z� <br />SU" ❑ WKOTH LENGTH <br />DEPTH DISTANCE TO NEAREST. WELLFOUNDATION PROPERTY LINE <br />DISPOSAL PONOS ❑WIDTH LENGTH <br />DEMI DISTANCE TO NEAREST: WELL FOINNDATION PROPERTY ONE <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WONT WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDWANCES AND STATE LAWS, AND RUES <br />AND REGULATIONS OF THE SAN JOAOURN COUNTY. HOME OWNER OR LICENSED AGENT'S SKME CERTIFIES THEMUDWINO: 7 CERrWYTHAT INTHE PEPEOIaAONATANCE OF THE WORK FOR WHICH <br />THIS PFIMBT IN ISSUED, SMALL NOT OY ANY PERSON M OWN A MANNER AN TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUWRMA.' COWRACTOWN Howie OR <br />NT BIO TUE Cl1R N THE FOLLOVNNO; 7 CENTIFV THAT N THE PEREORMANCE OF THE W01K IDR WHICH TMS PERMI IS ISSUED, 1 S1A11 EMPLOY i'EitSONa BUBJLCT TO <br />a N 10 LA CAUFOUNIA.- TNF ANT MUST CALL H NOW M ADVANCE FOIL ALL REOU M MBPBCTIONS. COMPLETE DRAWING BELOW. <br />SIGN x 'I �- / [ ! TITLE: V-7� DATE: r / r <br />PLOT PUN (DRAW TO TK:AIEI IN:ALE - b <br />T. NAMES OF STREETS ADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM ON PROPOSED <br />2. OUTLINE OF THE PIIOPCIITY, WITH DIMENSIONS AND NORTH DIRECTION. EAPARBIOH OP SMAOE DISPOSAL SYSTEMS. <br />9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 9LRI/CTME8, 6. LOCATION OF WELLS WITHIN RAOM OF ONE HUNDRED FIFTY FT. ON <br />INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br />APPLICATION ACCEPTED BY <br />TAM,e OR SUMP INSPECTION BY� <br />ADDITIONAL COMMENTS: '--747' <br />AceovNTIRg oM.r: <br />PE CODE EEE IMT'O AMOUNT RFAa1TFD Cl/EI <br />r O �- <br />Pub. Haatth Serv. - ErmrO, 171 (3/86) <br />FOR DEPARTMENT USE ONLY <br />AID# 1 FAC,. II <br />mom m By I DAT6r I on I PsvM NMLam <br />INVOICE P <br />-1- <br />'79 <br />