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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O.BOX 3M$04 EAST WEEPER AVENUE,STOCKTON,CA VMI-88 <br /> 12091 438.3420 <br /> NDN-REFUNDARLE PERMIT EXPIRES I YEAR,}ROM DATE 18SVED <br /> IGmpkIB k Trblk$tid <br /> AFPUCATHON K HEREBY MADE TO THE Sµ JOAOUB+COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INBTAU,THE WORK DESCN-ED. THI!APPUCATgN 18 MADE M CDMPIJANCE VATH BAN <br /> JOAOUN COUNTY DEVELOPMENT TITLE,,1CHAPTELRR 9-11110.3 AND THE STANDARDS OF GAN JDADUM COUNTY RRUC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMBVJN, <br /> JOB ADORE88IOR A[PN,, �1-7 14. 'f A`t c 1+J .. _`Cfry S'i[�L-I`-`�1.N _ LOT 81;E ae-4-c S <br /> OWNER%NAME p.�.-2j1"Tv,� ADDRESS PHONE <br /> CONTRACTOR f FC I ` ��•/• i /!y/: /� <br /> ADDRE88 LICE 13-5 /Y_PNONE G/'6 <br /> BUB CONTRACTOR REGRESS LACE ^�Y- pq <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION RBAH/AmT10N ❑ DESTTU... <br /> WD SEPTIC SYSTEM PERMrTTED IF FVBLHC GEWEF IS AVAILAME WRHNI 200 FEET OF MALDIHG.1 pEtC TEATI 1 I IN"MANY <br /> ,,z Appllutlpn• <br /> NISTALLATION VVRL SERVE: RESIDENCE EL1 COMMERCIAL❑ OTHER❑ <br /> NIA NNER OF UVINO UNITS:_L IWWAaM OP f DOMi: ' MUAIfBI OF BLIFLOV�i: _..­y.�0 <br /> CHARACTER OF SOIL TO A DEPTH Of 3 FEET:' •i - PR/BUMP SOIL CNA--.:� '{yX ATER TABLE DEPTH <br /> IE ❑PM TANKIOREASE TRAP TVPEAAFO CAPACRY _NO.COWARrMENT'f <br /> ►1[O TIIEATMERT PLANT❑ DMTANOE TO MEARiBT: WELL FOUNDATION 2(J g riRry LINE <br /> LIFT STATION❑ SIZE TYPE OF PAIAP GANG OIL 8EPARATOR ENCLOSED SYSTEM? T�• J^ <br /> LEACHING UM! Cr-NO.E LENGTH OF uNES—P—— N DISTANCE TO NEAREST:%ML, _KJUNDATION `� PROPERTY LINE L C, <br /> FILTER FFD ❑WIDTH LENGTH _DEPTFI pSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> AROUND® ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL f _*FOUNDATION PROPERTY LIRA; <br /> ����AOE ATS ❑OF➢TH }B¢E _NUMBE���DISTANCE TO F/EAPEBT:WFLLIJ_FOUNDATION 7��i HgP'ERTY UNE L /i'�_ J <br /> ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P1VfERTY LINE <br /> OIBPO$AL POND$ ❑WIDTH LENGTH DCPYH DIBTAMCE TO NEAREST:WELL_ FOUNDATON PROPERTY UNE <br /> I HEREBY CERTIFY THAT I NAVE PREPARED THIS APFLICATION AND THAT THE YJORK wlll 6E GONE IN ACCORDAHC!VMH BAN JOAOUW COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR UCENSEO AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'l CERTFY THAT IN THE PEAFORIMANCE OF THE W01K FOR WH ICN <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MMYIEII AS TO BECOME SUBJECT TO Vary Mµ'B COMPENSATION LAWS OF CAUFOPFMA.. CONTRACTOR'S HSSNG OR <br /> SUBCONTRACTM SIGNATURE CERTIFIES THE FOLLOWER:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOPIL FOR WHICH THIS PERMIT 18188VED,I$HALL EMPLOY PfPaONS SI/BJECT TO <br /> WOR(MAN'8 COMPENSATION IAWB,GFCA(,lFORNIA,' THE APPLICANT MUST CALL 34 HOURS IN AbVANCE FOA AL111EgINWp 1N$PBCTgMS. COMPLETE DRAWING BELOW, <br /> SIGNED X i � Tftl{: DATE: <br /> T oG PLOT PLAN MR AW TO SCALEI SCA:.E •Ie <br /> 1.NAMES OF STREETS OR ROAOS NEAREST TO OR BOUNdNG THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOBAL SYSTEM PRIOPOBED <br /> 2-OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH INFECTION. FJIPAN&ON OF fEWAOE Dremeµ,SYSTEMS, :� <br /> 3.OIMENBIONEO OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED STRUCTURES, i, LOCATION OF WELLS WITHIN RADIU8 OF ONE M/NDFED FlFTY FT.ON <br /> f/CLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK8. THE PROPERTY OR ADJOINING PFOpERTY, <br /> IT :---- <br /> . . <br /> /bpi <br /> 0 <br /> . c <br /> L. <br /> C ` POR OEPM'�MIENT USE ONLY <br /> AJ'PllCpigN ACCEPTED BY Y�.i_�...... I —11: 1Q AREp; <br /> \ G <br /> TAW,PIT OR BUMP INSPECTION 6Y DATE I I FINAL INSPECTION BY <br /> ADOFTIONAL COMMENTS: <br /> ACCOJNTINO ONIY: Aqf FACI S RD ' <br /> iE COD! FEE INFO AMOUNT RHNTTED CF1EC lCABH REC@VED 6Y DATE M/PEYyiT NL$NB81 <br />