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�. APPLICATION FOR LIQUID WASTE PERMIT <br /> 1.lOAOUIN COUNTY PUBLIC HEALTH s.jRVICES- <br /> '-k ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 . <br /> FILENON-REFUNDABLE COPY <br /> PERU P RE8 YER FRO DAZE ISSUrp <br /> APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTTpRUUC�T ANp1OR�8TALL THE WORK DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE w(TH BAN <br /> JOAQUM COUNTY DEVELOPMENT TRIS,CHAPTER 8.1110.3 AND <br /> THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH BERLVICEB,ENVIIIp <br /> JOB AObRE86fOR APNN �� �, NMENTAL HEALTH DIVISION, <br /> OWNEA'@ NAME � j r�/ LOT SIZ� I <br /> COHfADDRESS PHONE C7 — <br /> MCTOR�Q�rO,y '�G.__•.—ADDgE66 � �. chw�c�'f. /�7 S f <br /> ucr r PRO <br /> NE 3` 3`f3 <br /> BUB CONTRACTon - <br /> ADDRESS <br /> PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> REPASVAbDlT10N bESTRUC710N❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BuImNG.I <br /> PH1C 7EST(i!1 1 NOW MANY <br /> INSTALLATION WILL @ERVP• RESIDENCE❑ COMMERCIALS OTHER [ ,� APPS on r <br /> j <br /> . NLIMBHI OF LINO UMTS: NUMBER OF BEDROOMS: �b <br /> CHARACTER OF BOIL TO A DEPTH OF 3 FEET PR/BUMP SOIL C <br /> HARACTER; WATER TABLE DEPT <br /> E�fmmvmt"T <br /> ICHitEA@E TRAP ❑TYPEJMP 1f •CAPACITY C �®Q C - k/ NO,COMPARTMENT <br /> 4 PLANT CI DISTANCE TO NEAREST: WELL DQ10 FOUNDATION O <br /> LIFT STATION❑ SIZE I PROPERTY LINESSS; <br /> �] TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMS' 7e i <br /> LEACHING LINE Ste' NO.8 LENGTH OP LINES `lDC7• <br /> %� 5 DISTANCE TO NEAREST..WEL 3<. t��O fOUNDATION_!� PRgPERTy LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL.! - . <br /> FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WROTH LENGTH � DEPTH <br /> DISTANCE TO NEAREST-WIfLLI. FOUNDATION PROPERTY L�NF <br /> SEEPAGE PITS ©DEPTH 812E - NUMBER DISTANCE TO NEAREIT W�LLI<" "..r <br /> - FOLINDAT'ION PROPERTY LINE <br /> SUMPS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST'WELL .-. <br /> FOUNDATION... PROPERTY LINE <br /> RHSPOSAL PONOS WIDTH LENGTH DEPTH DISTANCE TO NEAREST- <br /> ��,_FOUNDATION PROPERTY LINE <br /> t <br /> I HEREBY CERTIFY THAT 1 HAVE PREP D THIS APPLICATION AND TH E WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,—AND RULES <br /> ANO REGULAT1pN6 OF THE 8AN JOA IN COUNTY.NOME OWNER OR EN O AGENT'S SIGNATURE CERTIREBTHE FOLLOWING-•ICERTIFYTHAT IN THE PERFORMANCE of THE WORK FOR WHICH <br /> THIS PE 186VE0,1 NOT oy ANY PERSON M SUCH MA R AB TO BECOME SUBJECT TO IHORKMAN'S COMPENSATIoN LAWS OF CALIFORNIA.• CONTRACTOR'@ HIRING OR <br /> SUBS AN*@ BM3NA10 CE FOLLOWING: CERR E-P!ltl OP THE IfM m Fon WMCH Two PERMR IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORK AN'B CO N TID WB RMA•• THE T MUS CALL 24 HOURS IN ADVANCE IRALL 7ED INSPECTIONS. COMPLETE DRAWING BELOW <br /> ` <br /> SIGNED TITLE: DATE:—..�— <br /> Ir PLOT PLAN(DRAW TO SCALE)SCALE •M <br /> 1, NAMES OF BTREETS OR ROADS NEAREST TO OR BOUNDING THE p110PERTY, <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> INCLUDING COVERED AREAS OUCH AS PATIOS,DR IVEWAy WITHIN RAMSHUNDRED FIFTY FT.ON <br /> . @ PRO OOTION OF R LS <br /> ..... -..... ..,..... ..: ., - ..s 6, 4 THE AxI'ERTy ` ADJOINING ... <br /> B AND WAU2B <br /> ••..rn.w.i.,. PROPERTY VISE <br /> b A ICA] : 111 <br /> j. : <br /> �a- <br /> .... <br /> � P�NUC ...., LL�R�� <br /> ;....... ...... ............;....... <br /> In I <br /> 4 <br /> U <br /> U <br /> f!d <br /> E <br /> .......:......... <br /> ::..MEN <br /> rAL iitr�tr vrce, <br /> ON <br /> ............... .. <br /> n . <br /> : <br /> e, .... <br /> .. ..:..... ....... lav sem.:...._...... ...... ......,.. ............. ...... <.......'......'.....'...... '..... <br /> ., ._......... .................... <br /> ...... ..;.. <br /> FOR DEPARTMENT USE ONLY t - <br /> APPLICATION ACCEPTED BY DATE, Z <br /> AREA— <br /> YANK.PTT OR BUMP-NSPECTLOH BY ATE_ I / FINAL INSPECTION by <br /> ADDITIONAL COMMENT8 <br /> I? <br /> 10 <br /> ACCOUNTING ONLY: AID/ - FACS . <br /> 9E CODE FES INFO AMOUNT RbMITED CIBB:IiT ASN RECEIVED BY DATE SR I PERMIT NUMBER INVOICE r <br /> Pub.Health Serv.-ErMro.174(3186) <br /> Ze0 <br />