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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SL-AVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 "I'1j.: (209) 468-3420 I� k�,,,,, NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �,j /� 0 ICBmplatB in Triplicate)te) 1"` APPLICATION IB HEREBY MADE TO THE BAN JOAGILRN COUNTY FOR A FERNIR TO CONSTRUCT ANDNA INSTALL THE WON(DFB RUUD. THIS APPLICATION M MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TRpUE.CHAPTER 8-11101..3-AND THE STANDARDS OF SAN JOAGUN COUNTY W&M HEALTH BE�R`V 90.ENfN-IgLN�MEMAL HEALTH dVMION. JOB ADORESS/OR APNF1n� I D 5 o .5. 'Noor AGN "`^ PWA-sr' l— CRY J I-ocy- \�' h ['LOT ERE_-T OWNER'S NAME I✓'p VI,<. U� D A.C- ADDRESS 3)x rY(aS (.tl 0-yCltMK1M1+0 MORE J/�� CONTRACTOR 0.V Irt$ h /SC o-5 ADd¢BB L'/'OVO N, 4u J -SCN Z. cE- uDF 100511 FNDN [F4 E (o -?6c7 BUS CONTRACTOR �C ADDRESS IICF FNONE TYPE OF SEPTIC WORK: NEW INSTALLATION REYAINAODITION ❑ DUTMGIGN 13 IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUI DING.1 FUII TUTHI I 1 NOW III INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALA OTHER ❑ NUMBER OF WHO UMTS: NUMBER OF SEMOOMB: NUMBER M YMPLOYEEJ: CHARACTER OF BOIL TO A DEPTH OFFp 3Et FEET: PITMUMP SOIL CHARACTER: WATER TABLE OEPTH r�arJvS c' SEPTIC TANI/OIWE TRAP Ip1VPF11AF0 CVC.-. CARACRY c7D NO.COMPARTMENTS n PKO TREATMENT PUNT DISTANCE TO NEAREST: WELL FOUNDATION 1 L P110PERTY UNE V J / LRT STATION❑��1mZE �I TYPE OF PUMP BAND Ol EEPMATOR(ENCLOSED SYSTEMS PROPIERTY UNE RILTTEER:EDU`�) I&W NTH LLN�I, 1 LENGTH L T) DEPT/ DISTANCE TO NEAREST:WELL L L MUNDAMN C7 L PROPERTY UNE ld(7 L MOUNDED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE HTB ❑OEFTH SDE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMM ❑WIDTH LENGTH DEPTH OMTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS [I WIDTH UENOTH DEPTH 06"A ETO NEAREST:WELLFOUNDATION FROPATY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOHE IN ACCORDANCE WITH SAN JOAUUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAI JOAQUIN COUNTY.HOME OWNER ORMENSED AGENT'S SIGNATURE CERTIFIES THE FOLLDWNO:'I CERTIFYTHAT LATHE F£POFNI N f OFTHE WOR(FORWIRCH THIS PERMIT N LINED,1 MALL HOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME WWECT TO WORKMAN'S COMPENSATION LAWS OF CALAOPRA.- CONTRACTOR'S HIRING OR SUE CONTMCTINO ATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO WHICH THIS PERMR 18 ISSUED.I MALL EMPLOY PERSONS WWECT TO NOIKMAN'S EOMiNS41ON ,ILA�WS OFCNJFORNI(. TT' MtITLE HE A /CANT MUST CALL 24 HOURS IN ADVANCE FOR All MOU-�+R.E�D`INSPECTIONS. COMPLETE DMIN WOBOE `W. BONED X_ V'tel- � ` T : t {, V .- 1 _DATE: POT PUN MIRAIW TO SCALE)WALE *10 1. NAMES OF STREETS OR RDADS NEAREST TO OR SOUNDING THE PROPRTY. S. LD,,AT,N OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPRTY.WTTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE dHOBAL.SYSTET.U. 3. DIMENSIONED OM NEB AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WA1X8. THE PROPERTY OR ADJOINING PROPERTY. Za X 1 I i L �c A(-'I, I `� w fpr J� p C J L'r eve c©, U cLly r .. LO � _ 90 (, v, .... �Lh L ,,--y"..FOORR�DEPARTMENT USE ONLY �, '�-/L'•`(l" l.( [\ l..(.(.W`tn-i\N� DATE: (�1 AREA: API-ICATION ACCEPTED BY Lip TANK,PIT OR SUMP INSPECTION }�5 DATE / / FINAL NSP6CTION BY ATE 1/_I- J ADDITIONAL CO MEMS: a� C U�11 M IAS he ACCOUNTING ONLY: No, fACI FE CODE FEEINFO AMOUNT RDGITE CNEC /CASH RECDVED BY DATE M/RMT NUMBER 71=17 Pub.Hearth SEN.-Ewro.174(3/'96)