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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38% 304 EAST WEBER AVENUE,WOCKTON, CA 9MI-988 (20 1 489.3420 NON•REF N6 BLE PERMIT EXPIRES f YEAR M OAISSUED ICSIRPMIB Is TrIpR@Btpl APPLICATION M HEREBY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOA?R INSTALL THE WORK DESCRIBED. T► a APPLICATION It MADE IN COMPIJANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TRLE,CHAFFER 8-1 1 10.3 AND THE STANDARD@ OF SAN JOAOUIN COUNTY PUBLIC HEALTH SEEeeRVIKEB,""Oh NIONNMEENTAL HmTI/DIVImm- JOB ADOREBSIOR APNe CITY� yIc2 ,LOT BIZEC OWNER'S NAME aid,4 _ AODRESB �S�l C` .� 'E1)1J P J1T"ZZi 4- 4 PHONE CONTRACTOR ADORF88 L1C1 PHONE SUBCONTRACTOR, r � ADDRESS- p UCr42,?g-g-=2 pHDNE TYPE OF SUTTIO WORK: NEW INSTALLATION RCPARVADDIT'ION ❑ DEITRUCTNIM 0 INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WfTHIN 200 FEET OF BUtLOIN0.1 PM TSSTh1 1 I NOW MANY AvvEe.de�s INSTALLATION WILL SERVE: RESIDENCE.V COMMERCIAL ❑ OTHER 0 NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: -el ` NUMBER OF EMPLOYEES; CHARACTER OF BOIL TO A DEPTH Of 9 FEET:_ PrT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPEIMFO / r�r�-Li _CAPACITY_- f�ff� _ NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL F- FOUNDATION S PRRoP�ERTY LINE T LIFT STATION 0 SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSrEMF LEACH"LINE t3 NO-S LENGTH OF LINES—&,— DISTANCE TO NEAREST:WELLF'JUNDATION�fFROPMW LINE FILTER SID El WIDTH- LENGTH _DEP 14 DISTANCE TO NEAREST:WELL -FOUNDATION PROPERTY LINK_V MOUNDED ❑WIDTH LENGTH._DEPTH DISTANCE TO NEAREST:WELL FOUIMATION PRROPOITY LINE SMAGE PFTB ❑DEPTH SIZE _NUMIIER DISTANCE TO NEAREST:WELL FOUNDATION F FAmq TY LINE SUMPS O WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WE11—_ FOUNDATION PROPERTY LINE y DISPOSAL POND@ 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_,_FOUNDATION PROPERTY LNE N F1ElERY CFATNY THAT I IFAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WTI'"SAN JOAOUML COUNTY OFONIANCES AND STATE LAWS,AND RULES Q ANDIEGILEJ1TIONBOFTHESANJOAOUWCOUNTY.HOMEOWWRORLICENSEDAOENT'SSIGNATURECERTIFIESTHEFOLLOWING,'LCVfflYTHATNITWFEIS'ORMANC{OFTIEV4OFKFORWNICH t+• THIS PEFOAM IO ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNEN AS TO BECOME SUBJECT TO WOFAMAN'S COMPENSATION LAWS OF CALIFOFSEA.• COMRACTOR'S NVOM OR @US•CONTRACTSIG SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR 1AI 41CH THIS PERMIT 18 INNUED,1 SHALL EMPLOY FlMDMS SUBJECT TO WORfMAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPLICANT MUST CALK.2S HOUR IN ADVANCE"AN ALL REOHSRED INSPIMONS. COWME DMWMIS NBOW. SIGNED x ■ TITLE:_ DATE: PLOT PLAN{UMW TO SCALE(SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIRE PROKIrry. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. a. DIMENSIONED OUTLINES AND LOCATION Of ALL ExIWrRM AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNMO FIFTY FT_ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK@, THE PROPERTY OR ADJOINNNG PROR'ERI'Y. FOR DEPARTMENT USE ONLY AP PLICATgN ACCEPTt"BY - DATE: AREA:_,TANS,"T OR SUMP INSPECTION"BY DATE _ 1 1 FINAL 416 CTLON R!Y PATE�1 I ADDITIONAL COAMMENTO: ACCOUNTING ONLY: AIDS FACIF IE CODE FEE INFO AMOUNT REMITTED FIEC f/CASH RECEIVED By DATE SR 1 PEMINT NLSYBEI "Amon I 421 1 a. 00 z Jr i SSG