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^PPLICATIUN FOR LIQUID WASTE PERMIT y <br /> SAN .,AQUIN COUNTY PUBLIC HEALTH SEFRY.CE:S <br /> ENVIRONMENTAL HEALTH DIVISION a <br /> 364 EAST WEBER AVENUE,STOCKTON,CA 95202 07 0/Zv ?L <br /> F" <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I TEAR FROM DATE ISSUED <br /> ICBmPIBte In Trglie$t6► <br /> APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIDR INSTALL THE WORK DEGCRISED.THIS APPLICATION 18 MAGE IN COMPLIANCE MIH BAN <br /> JoAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOOIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OIVISION. <br /> U CITY Lot mzE <br /> r 1 JOR ADDRT68ATR API/ !. y-- ' � G J _ <br /> .OWNER'S NAME A! ss '�---ZGz. <br /> R CONTRACTOR ^/ e4A APDRE66 Cf MIONE <br /> SUBCONTRACTOR -A'DDRE$S m/ m/ PHION­E <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ 11EPAIRIAODMON❑ DFATRUCTION N✓ <br /> INO SEPTIC SYSTEM PERMNTEO IF PUBLIC SEWER IS AVAILABLE WITHIN 300 FEET OF BUIUXNG,I f9LC TTAT7+1 I 1 HOW MANY <br /> ApPMIE�Son/ <br />+J I $NcTA TION WILL BONE RESIDENCE❑ COMMERCIAL❑ OTHER❑ <br /> /- NUMBER OF&VINO UMTS: NUMBER OF■EOROOMS- NUMBER OF FMMOYEU: <br /> CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PTTISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANVOREASE TRA�-P ❑TYPE/MFO CAPACrTY NO.COMPARTMENTS <br /> PKG TREATMENT PLANT 0 DISTANCE TO IIEMEAT: WELL FOUNDATION PROPERTY LINE <br /> NFT STATION ElSTZE TYPE OF RUMP SAND OR SEPARATOR IENCLOGED SYSTEMI <br /> LEACHING NNE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL roIAVDATION PRORRtY UNE <br /> I� ALTER BED ❑WIDTH LENOTH DEFtH DISTANCE TO HFAREur:WELLFOUNDATION PROPERLY LINE <br /> F ' MOUNDED 0 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> I' tEEPAOE PITS O OEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE _ <br /> SUMPS 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL roNOB O WIDTH IENOTN DEPTH DISTANCE TO NEAREST:TYLu <br /> rOUNGATIUN PROPERTY UNE <br /> r <br /> f <br />} IND REOEBY CERTIFY THAT I HAVE PREP l$AIPLICATNON AND THAT THE WOFEC WILL bE DONE IN ACCORDANCE WITH BAF JOAQVIN COUNTY ORDINANCE$AND STATE AWB.AND RULES <br /> y <br /> AND <br /> REGULATIONS OF THE BAN JOAOIII O NTY.mbmc OWNER ORUCENBED AOEM•B BIONATURE CERTIFIES THE FOUAmNON'I CERTIFYTNAT M THE PERFORMANCE OFTHEYVOR(FOR4Y111CH <br /> J TMB PERMrr IS ISSUED,1 SMALL NOTE R ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOMMAH'S COMPENSATION LAWS OF CILLIFORNIA.'COMIIACTDR'B H119M8 OR <br /> SUB.CONTMCTINO BIONAT CERT IF -HE FOLLOWING:R CERTIFY THA71N THE PERFORMANCE OF tH£WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBACT TO <br /> WORKMAN'S COMPENSA NLA RMA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL IIWO�I,I/M IKSP.E�C,T.ITON{.COMPUTE DIAWIND BELOW.p+y <br /> } SIGNED X U '�� TITLE' <br /> 1 E$ C <br /> ROT FUN IDR\W TO SCAM SCALE �In <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNGINO THE PIIDPERTY, 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FRIOPOSEO <br /> 3.OU4LWE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAOE OISroBAL BYS"t. <br /> 0.DIMENSIONED OUTLINES AND LOCATION OF ALL.EXISTING AND PROPOSED SIRUCTVRFS, S.LOCATION OF WELLS YNTNIN RADIUS OP ONE HUNDRED FIFTYFt.00 <br /> INCLUDING COVERED MEAS$UCH AB PATIOS,DISVEWAY$.AND WALKS. THE PROPERTY OR ADJO9GNG PIOPERTY. <br /> ....'........... .. :... <br /> `... <br /> .......o..... -. .......- .. 1 v - - <br /> " C1 <br /> .. - --- <br /> � ' Sr - <br /> . <br /> - - <br /> p ; <br /> :: <br /> t ... :... . f <br /> r-0R OFPM7MEN7 USE ONLY APIA: A <br /> AFPTJCATION ACCEPTED 8Y/W � I✓V`1 _ DATE: <br /> �} TANK,PT OR SUMP INSPECTION BY DATE / -�_FINN.INSPECTION BV DATE I / <br /> r 1 ADDITIONAL COMMENTS: <br /> ACCOIJNTSNO ONLY: AIDE FAC•. - <br /> 1 { <br /> F i <br /> F -- PE CGDE FEE INTO AMOLMT ITFA CIIECK/I(7C�A$H RECEIVED BY DATE iRlP9VA1T NUMBER INYOIOEf <br /> I 7 � <br /> Pub.Health SerY.-Enviro.174(3196) <br /> L <br />