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APPLICATION FOR LIQUID WASTE PERMIT <br />SAN-JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P,O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON. CA 55201.988 <br />(208) 408-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />K.mRpISd in TrIpHomial <br />APPUCATION IB HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO)OR INSTALL THE WORK DESCRIBEO, THIS APPLICATION M MAGE IN COMKiANCE WITH BAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1110,3 AND THE STANDARDS OF SAN .IOAOUM COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADOF4651OR A— ,�• Ia: �. r +^rJ i C CffY /I I A< <br />✓'}•ri _LOT SJZE_ <br />OWNER'S NAMEJiva'1 f. :_. ADDRESS PHONE <br />CONTRACTOR ADORF.SS T LICE PHONE <br />• <br />SUBCONTRACTOR L }";,� en ADDRESS <br />TYPE OF al"C WORK: NEW INSTALLATION �~ "WARVADDITION ❑ DESTRUCTION ❑ <br />NO SEPTIC SYSTEM PERMITTED E RJBiIC SEWER IS AVAILABLE `MTHRN 20ofEET OF SUILL,".) P I RC TESTMI I I MOW MANY <br />� <br />/ APPSooson <br />INSTALLATION WILL SOIVE: RESIDENCE L.` COMMERCIAL ❑ OTIiER I) <br />MRIANOI Of LRVUO LINr7s:__ NLMIL M W NEDROOMS:NUMA I OF FMPHDYFW: <br />C/WIACTER OF SOIL 70 A DEPTH OF7 ` i <br />N PITMUMP SOI CHARACTER: �'I WATER TABLE DEPTH <br />tlrT1C TANII/fR1EASE TRAP LT TYPE�fFO_L (r t?JIr <br />i J APACfTY NO.COMr'ARTMEMB� <br />RID TREATMENT RANT ❑ IMSTANCE TO NEA UT: WELL �_� FOUNDATION 10, PWWRTY LINE_. I op <br />LEFT RATION C] SIZE TYPE OF VJMP SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACHM UNE 9_1 . A LENOTN Of LINES L4 = L{ )I INS fANCE TO NEAREST: WELL t FOUNOATON PROPERTY LINE �Q f <br />RLTFIR SED 13 WIDTH LENGT4 __ DEPTH DISTANCE TO NEAREST: WELL FOUAAT)ON MRCPCMY LINE <br />MOUNDED ❑ WIDTH LENGTH _ DEPTH DISTANCE TO NEAREST: YELL__ FOUNDATION PROPERTY UW_ <br />SmAOE FITS 11 DEPTH SIZE NUMNER I DISTANCE TO NEAREST- WELL FOUNDATION_ PROPERTY LINE <br />=LIMPS Nl WIDTH _ LENd TH�' DERTH�y� DISTANCE TD NEAREST: WELL__L3 t FOUNDATIONT3 PROPERTY UNE n <br />i' U <br />DISPOSAL PONDS 13 wDTH LENGTH IYPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />I HEREBY CfATIIY THAT 1 HAVE PFIEPARED THIS ARRUCAMN AND THAT THE WORK WILL BE DONE *4 ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES AND STATE LAWS, AND RUES <br />NS <br />AND IEOULATIOOf TRE BAN JOAWN COUNTY, HOME OVYNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIM: '1 CERTIFY THAT IN THE PE (FOR MANCE OF THE WORK FOR WHICH <br />THIS PERMR IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME NUSMCT TO INOMMAN'S COMPENBATON LAWS OF CALIFORNIA.- CONTRACTOR'S IIfum OR <br />SUSCONTRACTINO SIONATURE CERTIFIES THE FOLLOWwO: -1 CERTIFY THAT IN 'HE PtTIFOMIANCE Of THE WORK FOR WHICH THIS PERMIT IB ISSUED, I SHALL EMPLOY PERSONS BUBJECT TO <br />WORKMAN'S COMPEENSSSATTIO/LNN�LAWS OF CALIFORNIA.-jj/fjIFA.�TTHE AFFUCANT MUST CALL K HOURS M ADVANCE FOR ALLL' REQUIRED RSPIC1TONs. COMPLETE ORAWRq (STOW. �` �✓ <br />61d Nf0 M_ t ? -' - �/ NYi'Tr ' TR!.E: `T IJG Gti �l O L f a 1 DATE: /' l -I �] <br />PLOT PLAN (DRAW TO SCALE) SCA: E ' to <br />1. NAMES OF STREETS OR TOADS NEA EST TO OR SOLMDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, WITH OWENSIOFIS AND NORTH DIIIECTON, EXPANSION OF SEWAOE DISPOSAL SYSTEMS. <br />] DIMENSIONED OUTLRES AND LOCATION OF ALL EXWTRIO AND PROPOSED STRUCTURES, S. LOCATION Of MLLB WITHIN RADKUB Of ONE HUNDRED PIETY FT, ON <br />THE PROPERTY OR AOJOININO PROfiATY. <br />1 <br />...:......: ..... <br />[ � AR'ti•� <br />Nov. <br />dov. Ito <br />vir, JI <br />JL IT RH <br />al <br />FOR DEPARTMENT USE ONLY S c_ <br />A PLICAMN ACCEPTlD SY DATE: I V ^ �+ MEA:,•_,11 I <br />TANG, PIT OR SUMP INSPECTION BV GATE_ 1 1 FINAL INSPECTION BY DATE I ' I D) 5 <br />^, ADDrnONAt GOSM.IENTB: <br />ACC—tTINO ONLY: I AIOO <br />FAC/ <br />I COOS 1 FEE INFO 1 AMOUNT NERARTTEO IkUMECKOXASH I RECEIVED RY I DATE I OR I P61MT MUFMIlI IINVOICE t 11 <br />