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` APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SL14VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES A YEAR FROM DATE ISSUED (CFmpIBte In Triplicate) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCAMN IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENNTT TITLE.CHAPTER 9-1110.3 AND THE"A`mutme S OF B(((��A)))//N11 J AOUN COUNTY PURIM HEALTH NFIVICEa.EN•V/IµRDNMENTK HEALTH DIVISION, JOB ADORESSMR APNP�1^111)3(D �, lia r IAti '^ Cm �E,e/`KeI V�_ LOT SIZE OWNER'S NAME c ADORES87�''//O0�•TE��`Z/ t(H�ILl Ck ,�••`) 5;411 L 4M:Ed PHONE V ✓ /�O 7/ CONTRACTOR �r-1-1�LJ \ L1 r�, ] ADDRE66"j6N) �` (A") `-VA) W A�Mc#/L!�J _PHONEA&ID BUB CONTRACTOR ADDRESS lMS PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION BEPAIRIADDITON ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PIUBUC SEWER IB AVAILABLE WITHIN ZOO FEET OF BUILDING.( PSI C TESTHI I I HOW MANY APNlmden S INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER Cl NUMBER OF WHIG UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: / CHARACTER OF WIL TO A DEPTH OF O FEET:S PT/HUMP SOIL CHARACTER: WATER TABLE DEPTH /� SEPTIC TANKRXREASE TRAP �TVPE/AIFO CARACRTY NO.COMPARTMENTS PLO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL . U FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED BYeTEMI LEACHING UNE ❑ NO.B LENGTH OF UNE8 DIBTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE RLTOL BED 2 )L ❑wor" l 7 f LENGTH DEPTH DISTANCE TO NEAREST:WELLELOLLFOUNDATION=PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLPOUNDATION PROPERTY UNE SAGE PTS ❑DEPTH WZF NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PPOPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL M DONE IN ACCORDANCE WITH SMI JOAMIN COUNTY ORIRNANCEB AND STATE)AWB,AND RULES AND WOULATIONB OF THE BAN"AMIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE KRIGIAMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, ALL NOT EMPLOY ANY PERSON W WCN A MANNER AS TO BECOME WBJECTTO MMMAN'B COMPENBATpN LAWS OF CA MMIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING NA URE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED.1 SNAIL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO NN LAWS OF CALJFORNIA.' THE UC ANT MUST CALL 2 HODU IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW, EAT SIGNED X " '1 /` TITLE: L DATE: PLOT RAN DRAW TO SCALE)SCALE__'I° 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE DIRECTION. . S. LOCATION OF HOUSE SEWAGE DISPOSAL SYGTEM OR PROPOSED _ Z OUTLINE OF THE RIO E6 AN WITH OMEN OF AL AND NORTH AND PR bN. EXPANBbN OF SEWAGE DI IN SALRAD US FIEMS ON ]. DIMENSONED OUTLINES AND LOCATION OF ALL EXHITING ANO PROPo6ED STRUCTURES, S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAY-,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..... \`JVD Bill 1111-4 I I , 1 _ _ v _ I I II � I I I i r � I „ I 6] L a 1 I I 12d}I21s0vn� e .... y u L, 19J`7 i P Ir 4 99 JA I D �Ai H6q�TNL�g rack Fllxcr�i< _ _ I ux (6�9�f 4 DIVISION. .. ip 1 12 APPLICATION ACCEPTED BY • (� POR.D� dT USE ONLY DAYS DATE / / FINAL INSPECTION .. -- TAW,RT OR SUMP INSKCTIOH,-B/4Y--/: o J'BBy ATE ADOMONALCOMMENTS' ��\" 9JaLI�J l' r � T J� �� 4� To, f LN pr R6NC N- IVO Plom 6 4PD.NJv ( - ~L ACCOUNTING ONLY: MDF FAG FEE INFO AMOUNT REMI ITER CHECK/ ABH RECEIVED BY DATEW/P9MI8 HUMam INVOICE• 25�i 9y l,6 3a4 q '7 33