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0016 Sk, APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH rcRVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplate In Tripliaats) APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WORK DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARD,OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. } _ JOB ADDREsamn APNE I 1 L4 0(9 p y 7�f A f S / CITU �sc'1f In (S LOT SIZE 30 OWNER'S NAME • SKI �+I✓TI`i r"LmJ ADDRESS r,•/ff1A / r T MONE *JY ��-7:�3� COMRACTOR IM ILr�UII CC ADDRESS 1% '� FJ1� �S UCF LP7"ZJ'4 PHONE,Y 39-777 SUBCONTRACTOR ADDRESS '�TLICI PHONE TYPE OF SEPTIC WORN: NEW INSTALLATION ❑ PUPMRIADDlT10Nly� DESTRUCTION ❑ INO ME IC SYSTEM PERMITTED IF PUBLIC 6EYlER I6 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TF1Tbl 1 1 HOW MANY `- AppYo�tlan F INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS I- NUMBER OF EMPLOYEES: CHARACTER OF SOIL TD A DEPTH OF]PEET: DC•Y/ PTI6VMP SOIL CHARACTER: S [PLATER TABLE DEPTH SEPTIC TANUMEASE TRAP ❑TVPE/MFO CAPACITY NO.COMPARTMENTS MG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑�SIIZZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEMS I I LEACHINO UNE to NO.S LENGTH OF LINES - 1"I,, DISTANCE TO NEARERT:WELL^P-,'.1FOUNDATION_POPERTY LINE_ FILTER REO ❑MOTH LENGTH OEM" DISTANCE TO NEAREST:WELL FOUNDATION PWPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATON OPERTY LINE BUMPS P' DTH LENGTH DEPTH I(7 DISTANCE TO NEAREST:WELL Ind FOUNDATION .1ti PRPROPERTY UNE 3�J DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST WELL FOUNDATION PROPERTY LINE - I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOA WIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:')CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERMWANCE OF THE MW POR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO VARKMAN-S COMPENSATION LAWS OF�CALJF RNIA.' THE APPLICANT MUST CALL 34 HOURS IN ADVANCE"R ALL REQUI)RE/D.INSPECTIONS. COMPETE DRAWING BELO SIGNED% V Tl .N TITRE: ��n T I L / LJ� GATE: ROT RAN(DRAW TO SCALE)SCARE_ 'Ro C 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE POPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DWVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. J6 C PAYMENT a AN 2 81998 U ••AIV JQ-AQvw C`CUNT.. P 8LACHEALTH 5EFiVfoES V7 i 21 .. 1.4,Fd- '.NW 8U HI=aLTH DNIS N 1:4 h v . FOR DEPARTMENT USE ONLY APPLICATION ACCEMED BY DATE: AREA'. TANK.LR OR EIOP INSPECTION BY DATE I NAL INSPECTION BY • OATEN ADDITIONAL COMMENTS ACCOUNTING ONLY: AID' FACS PE CODE FEE INFO AMOUNT REMIITEO LIIECIVICASH RECEIVED BY DATE SIR IPERMIT NUMBER INVOICEi 1 "r p U 7 11 Pub.Health SaN Enviro. 174(3/96)