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APPLICATION FOR LIQUID WASTE PERMIT AN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX M.304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (2091409,3429 FILE COPY NpN-REFUNAPEA ABLE Mii]EXPIRES IRE3 1! YEAR FROM DATE ISSUED C AITLIrATIuN IB HFnF.BY MAOF TO THE RAN JOADUM COUNTY FORA PERMIT TO CONBTRUCT ANDTriplicate) THE WORK DEACAIRED. THIS APPLICATION I8 MAbF IN COMPUANCF WITH BAN JOAOVIN CUUNTY DEVELOPMENT TITLE.CHAPTER 9.1 110.E AMT IE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB ADQRFSSIOR APHN f G�r _ 4.. t Pep C{TY - {I .-- LOT 8049CZ QWNFn'S NAMF_,7,q/yC-CL L { . E1 ADDRESS X. TPHONE_. %ZT CONIRACToR_ .. AD � " / / "CI J PHONE •.3 EUPI CONTRACTOR AODREa8 ,> n+aNE TYPE OF SEPTIC WORK: NFW INSTALLATION ..� REPAJRIADDITION ❑ OE,IRLICTION Q INO SEPTIC SYSTEM PERMITTED Ir FVNLIC SFWER IB AVAILABLE.WITHIN 200 FEET OF BUILE„Na.1 PMO TfSTHl f 1 NOW MANY AFPIeeIMn! INSTALLATION WILL SERVF: RESIDENCE❑ COMMERCIAL W OTHER❑ NUMBER OF WINO UNITS; NUMRFR OF BEDROOM/,;_ NUMBER OF BAPLOYECF; Cllq ITER DF SOR 70 A DEPTH OF:1 TEET }- y ,�PRISUMP BOILrCHARACTER�_IA�I�SfL1 WATER TABLE OEPTI{ �L�';'J I e pT1CJANKIaIFASE TRAP ❑Pym wr 'l([.�C.� {!'Re%T CAPACRY, /(4' QJ NO.COMPARTMENTS P%O TREATMENT PLANT❑ DISTANCE 76 NEARF,T: WELLz �"� FOUNDATION. 'j I AIOPERTv UNF„rcrC7 / •. UFT STATION❑ SIZE TYPE OF PUMP BAND OIL.SEPARATOR(ENCLOSED SYSTEMI LEACHSNO LINE NO.6 LENGTH OF LINES 'I— 7C' �'YI�1 OIBTANCE TO NEAREST:WELL/00�'f FOVNQATIO-� PRpPERTy IJNEyo I I FILTER BED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FDUNDATION 1 . PROPERTY LINE I MOUNDED ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE j} SFFPAOE PITS �DEPTH SIZE Cel NUMBEA f! `DISTANCE TO NEAREST:WE �i-FOUNDATION 7P 0 PRpPERTY UNE 3 (\} RUMPS ❑WIDTH LENGTH DEPTHS DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE i" nISPOSAL POND, ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE D I HEREBY CERTIFY THAT 1 HAVE PATPARED T1418 APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WT1/SAN JOAOVIN COUNTY ORDINANCES AND STATE LAWS,AHO RVLEB F1T AND RFOULATMNS OF TILE RAN JOAGUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK TORVVISCH 71115 PE.nMIT IB ISSUED,1 SHALL NOT EMPLOY APIY PERSON 1 SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS tlF CAIJPOPWIA.' CONTRACTOR'S HIMN,on f11 sun CONT CT O '10TL HE TOLLOVNNa CEITIN THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMT IS IBBUED.1 BHfALL EMPLOY PERSONS RUBJECT TO WORKMAN'B CO PErLITORNIA.' T A AMT MUST CALL 34 NOUKS IN ADVANCS FOR ALL REOIBRED INSPECTIONS. COMPLETE ORAWING BELOW.TITLE: 71L^ DATE: _ PLOT PLAN MRAW TO SCALES SCALE •to k 1. NAMES OF 8TIIFET9 OR TY,VV NEAREST IO OR AND NORT THE DIRECTION. TTY. <. LOCATION OF HOUSE SEWAGE 018POSAL SYSTEM OR PROPOSED 2. 0"TLINE OF THE PROPERTY,T LOCATION DIMENSIONS AL AND NORTH DIILECTOH. I ?. bIMFNSIONED OUTLINES AND LOCA710H OF ALL EXISTING AN 1770 BED UCT RFS, LO AT'ONNSION F TELLS W J41N RADIUS SYSTEMS. i INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,ANO /:OL87 _ V ��TI S. LOCATION OF WELLS ADJOINING N RADIUS OF ONE HUNDRED PK7Y FT,ON q, �- FCS THE PROPERTY OR 14OJOIkIHO ITOPERTY. !\1 A w ��'j - te i 1 , I 1 LL-0 1 JUL.: 7 199 SAN. )lllrF r;UC;p .. E.. - . .... .C7. - .. . . ...., - ,. .>..,,.......'--- ..., .,...., ..`P.Uf11JCJiL:P,LTti Sfa.VA,1.....,..._ p //� FOR AFPAAIMENT USE ONty 1 Z / nI'PI ICATIaN ACCEPTED AY_ _- / /'% _ DATE: AREA:. 1 AIM,STI oA RUMP IN.'•PTC TION A��Y'' �(( / DATE 1 I /FINAL INSPECTION BY DATE 7 AIMMONAL COMMENTS: �/'{�}'{ .'lST'�', S- C=Lp�j!! LJ p �' �Q--1_ f n� I�-� f- ca.4K-Tom^-,_�IIG .S5^�r-V^^^-C AC CO VN T IRO ONLY: AIDE FACN PF CODE TEE INPp AMOUNT REMITTED HEC IICASH RECEIVED By GATE �/ 6111 PUMIT NtIMSE�R INVOICE 9