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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468.3420 NONREFUNDABLE PERMIL EXPIRES I YEAR FROM DATE ISSUED (Cmpkta In TrIPAntEI APPLICATION Iv HEREBY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT 70 CONSTRUCT A MA INSTALL THE WORK DESCRIBED, TNS AFPLJCATION 1S MADE IN COMPUANCE YVRH SAN JOAWH COUN'IN DEVELOPMENT TITLE CHAPTER Q-1 110.2(AND THE STAN�DARO'(SS OFF SAN JOAOU N COUNTY PUBLIC HEALTH SERVICES,ENV) FIMENTAL HEALTH Or~N. JOB ADORESBAJR API/(Cgq-L"--(.J ,/rL,r1Q w�I, `•�(• W �/4I `y) L CT' } A C C� 1.�7T 812E CwM'S NAME/:--SLS I"I-r / O,• Ir.IL (` ADDREs ' -- a r—f- T �a W/ ts-2 ON Lac 3-1�r�3 coNTRAtroR E—w�r-�1 Ya� V l4�L(•�'" ADD4EPe S d �i-'} 1✓C/ LJc/S%S- L{ IN,HE BUB CONTRACTOR ADORES. LM/ :HONE TYPE OF SEPTIC WORK- NEW INSTALLATION❑ RRDAI —.TIGN❑ DESTnuer, IND SEPTIC SYSTEM PERMITTED IF VJBLIC SEWER IB AVAILABLE YMHIN?OO FEET OF SUILDINO.I f9lC TIGBTh1[I IfJW MANY TC�T AppBwdm I - INSTALLATION WILLSONE: RESIDENCE❑ COMMFNCIAL U OTHER❑ NUMB)1 OF LIVING UMTS: NIUMSER OF BEIXWOMB: NUMBER OF RPAPLOYEFS ."ARACRDI Of BOIL TO A DEPTH OF G FEET-_ PITISUVIP SOIL CHARACTER WATER TABLE DEPTH SE►M TANKMRLASS TRAP ❑TWEtMf.T CAPACITY NO.COMFARTMEMB Ftt0 TREATMINT►CANT❑ DISTANCE TO NEAREAT: WELL FOUNDATION PROPERTY UNE UFT STATION❑ BYZE TYPE CF PUMP SAND OR SEPARATOR ENCLOSED SYSTEM) lFACHI"UNE ❑ NO.S LENGTH OF UNEB_ OWANCE TO NEAREST:WELL FOUNDATION F'Ro"PTY LINE FILTER KED ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREBT:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WOTH LENGTH__DEPTII DISTANCE TO NEAREST:WELLFCVNOATION PROPERTY UNE SEEPAGE PTS ❑DEPTH Iva--NUMBER INSTANCE TO NEAREST;NAL fOUNOAMN NOPERTY UNE SUN APS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST'WELL ^FOUNDATION /BIO/ERTY UNE OISPOSAL PONDS ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELLS___FOUNDATION PEOFERrY UNE — I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TlA1 THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND ROARS AND REGULATIONS OF THE SAN JOAOLRN COUP".HOME ONMER OR LICEFIBED AGENT'S SIGNATURE CERTIFIEB TAE FOLLOWING:'I CHITIFY THAT M THE PEKdMEANCE OF THE WORK FOR WHIG H TNS PERMIT IS ISSUED,I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORCMAUFS COMPENSATION LAW.OF CAIIPOINA.' CONTRACTOR'S HIRING OR SUSLONTRACTINO SIGNATURE CERTMO THE FOLLOWING:7 CERTIFY THAT IN THE PERFORNIANCE OF THE WORK FOA WHICH THIS PERMIT IS ISSUED,I SIULLL EMPLOY PERSONS SUBJECT TO "MAN'S COMPENSATION LAMS/Offf CALIFORNIA-' M APPLICANT MUST CALL I EIOW EN ADVANCE FOR AL1 RE41UMM INSPECTIONS. COMPETE DRAMNOOJ BELOWy. +y I, SRO NED X /�" '' I TITLE._ DATE: u6 6 d ROT PIAN DRAW TD BCAIFJ SCALE 1. NAMES OF STREETS OR ROADS NEA EST TO OR BOUNDINO THE PROPERTY. Io4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOOM ].OUTUNF Of THE PROPERTY,WrrH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRCPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT-ON INCLUDING COVETED AREAS SUCH AS PATIOS.DMVEWAYS,AND WALKS. THE PRORRGY OR ADJOIM M PROPERTY_ __; ........... . .......... N m. P {VEID FEB 9 2flOQ COUNTY... ... ENVIR0Nn'FNTl' dF4LTH r)"!I';V : YVw�s l�� Zg� �,��,((qq//\��JJ�1� [�Jj� �.�■" T FOR QdMp/TIM_`;+�.1 I7'V/,SE ONLY 5 ///1 2— AG Qi TICN ACC171E0 B� • `""'�J V\ i ,L/,,Vn\_/IL�/. Wim(.LJ/`DATf: • `� M - 1 AN ml OR BUMP INSPECTION BY DATE / / FINAL INSPECTION By DATE AnLXTIDNAL COMMF:n s: �t RMIT fyf}S -02 btV S $NRy _ - ACCO VN nAO ONLY'. AJOI FAC' ^�-T1TI PE CCDE FEE— AMOUNT R@AIITED IIIX MAE. R£C PERMIT DATE SR/PEET MUNIGEn INVOICE/ Pvb Health SeN -Frvirc 174(3196) 2