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APPLICATION FOR LI0UI0 WASTE PERMIT <br />$AN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />�` I � ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON. CA 86201.0388 4� <br />�. <br />(2091450-3420 <br />WWREFUNCARLE PERMIT EXPIRES I Y AR FROM DATE ISSUED <br />lCB1IIplaw in Tripiksts) <br />APPLICATION 18 HEREOY MACE TO THE SAN JOACUM COUNTY TSR A PERMIT TO CONSTRUCT AND/OR INSTALL THE W RK DESCRIBED- THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8.1110.3 AND THE•STANDAADt OF SAN J�DAOL.4N PUBLIC HEALTH SERVICES. twRommFINTAL HEALTH DIVISION_ <br />(COUNTY <br />�l /. <br />D CA AvPr4 <br />�Ck <br />JOB AODREBBIOR APNJ'_ I -Y✓Q i._Q• CRY 1� 1,�=>t% -LOT SIZE h <br />♦�o,��/��-+�`.]`�n l <br />OWNERS NAME ft -J ADDRESS 4 I'RF=f"� ... PHONE <br />/1��¢�QY <br />��j`� <br />—/ en `��-E-'�- ✓ Ve <L39ii3 dz3 65 <br />: /,TV <br />CONTRACTOR_ / _ AomrGs IcS u-r-r0.�J LICIT iHaNE <br />SUS CONTRACTOR ADDRESS LIC/ _PMNE <br />TYPE OF SEPTIC WORK: AEW MBTALIJLTION ❑ REYMi/ADDITION DESTRUCTION 0 <br />DOO SEPTIC SYSTEM PERMITTED K PUBLIC SEWER IS AVMLABLE WITHIN 200 FEET OF BUILDING} <br />P91C 7E*T[FI I E Now MANY <br />,,r <br />ABplk*tlon / <br />INSTALLATION WILL *ERNE RESIDENCE 1;� COMMERCIAL ❑ OTHER ❑ <br />NUMBER OF UVTNG UNITS: j- NLUIMBEROFSEAH0oMS:__ 3 NUMBER OF SMPIDYEEA= <br />CHARACTER OF SOIL TO A DEPTH OF O FEET: 'I- PR/6UMP SOIL CHARACTER: WATER TABLE DEPTH <br />SEPTIC TANI RMEASE TRAP Q TYPEIMFO_ CAPACITY NO. COMPIJITMENTB <br />PKD'TREATMETTT PLANT ❑ USTANCE TO NEAREST: WELL FOUNDATION PROFI7(TY LINE <br />(�T� <br />. LIFT STATION 13612E TYPE OFYP�UMP SAND O& ISEPARATOR )ENCLOSED SYSTEM) <br />(V <br />O I <br />f� R P <br />Ld!' FWgIDATRON 7 �= PROPERTY NNE 2 a <br />LEACMNG UNE OT -NO, L LENGTH OF LINESI��7 �a L oltTANCE TO NEAAEBT: WELL L <br />O <br />FILTER BED ❑ WIDTH LENGTH DEPTH o18TANCE TO NEAREST: WELL RIUNOATION PROPERTY WIE <br />MOUNDED ❑ WTDTN LENGTH -OCFTH DIBTANCETO NEAREST: WET,L .FOUNDATION PROPERTY LINE <br />SEEPAGE N13TA DEPTH SIZE NUMBER UBTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />BUINFII D WIDTH LLTUOTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />DIISPOSAL POND* 1] WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PIIOPERrY UNE <br />2L <br />114EFFRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE w rm BAN JOAQUIN COUNTY OPOIm.4CE8 AND STATE LAWS, AND RULES <br />l.f <br />AND AFOVLATIONB SIF THE BAN JOAQUIN COUNTY. NOME OwNDR DR LICENSED AGENTS SIGNATURE CERTIFIES THE FOI.LDYNNG:'I CFAT6.YT4AT INTHEPEPFOAALAHOE OF THEWOFIRPORW"CH <br />THIS PERMIT IS ISSUED, 1 OHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WONUAAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S IMNO OR <br />z <br />SUB-COHTRACTING SIGNATURE CERTIFIES THE ROLLOwING: 'I CERTIFY TKAT IN THE FTPlORMAHCE OF THE WORK. FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WOPKMAN'8 COMPENSATION LA//[W1S OF CALIFORNIA: APPLICANT MUST CALL - HOURS IN ADVANCE FO1— R}E�O 191313 M11PECTON8. Cl— DMWMG .111, <br />1 ,'�+ I - ` 7 <br />SISNEO X TITLE: `-� DATE!o <br />PLOT PLAN WRAW TO SCALEI SCARE ' w <br />1. NAME* DF STREETs OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A_ LOCATION of HOUSE SEWAGE DISPOSAL SYSTEM OR PROFUSED <br />2. OUTUNE OF THE PROPERTY, WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />.T. DIMEwsmNEO OUTLINES AND LOCATION OF ALL EXISTMO AND PROPOSED STRUCTURCB, B. LOCATION OF WELLS WRIBN RADIUS OF ONE MUNEWID FIFTY FT, ON <br />FOR DEPARTMENT LIEF ONLY <br />APPLICATION ACCEPTED BY DATE' �% �•U �L I O lY AREA; Z�� <br />TANK, PIT OR SUMP INSPECTION BY DATE / I FINAL INSPECTION BY <br />�lDIT 10NAl COMMFMB: �r ltiD 41 r . h 7 /t' " J <br />ma <br />