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FPLICATION FOR LIQUIN WASTE PERMIT SA4-JOAOUIN COUNTY PUBLIC HEALTH SE9 ES clopy ENVIRONMENTAL.HEALTH DIVISION304 EAST WEBER AVENUE, STOCKTON, CA 9520 (209)468-3420 NON1_REFURDARLE PERMIT EXPIRES,I YEAR FROM DATE ISSUED (Complete im Trlplints) APPLICATION IS HEREBY MADE TO THE BAN JOAOUfN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED, THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMwr TWIT/LE.CHAPTER ^a-1110.3 AND THE STANDARDS ror SAV JO/jAQUIN COUNTY PUBUC HEALTH BERVICEB,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESBIORAPNI ` iS (pla�7y��'+✓�-/l��I,II�`- ,, ,�6 6(LA_ (_ IC.!' �1 crry G D 0/ 7 LOTBIZE OWNER'S NAME SW 171E ��14& y!- I/l//I_A_Ay Ilei ADDRESS -- - O]�. f�F C��l�f C4 PHONE_20-�-_y?L��Y01 CONTRACTOR F4C4 L-1 t/CEAVJ I'&1&rIou I'1�'(KIK-ADOREss �� .E 264,217 L1Cs PHONE? u !3 BUS CONTRACTOR_A -S�4� ADDREss i� r,�_-- �'L� Lrcr PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION - REPAJRIADIXTION ❑ DESTRUCTION 0 (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDfNG.I PERC TSSTI+1 1 1 HOW MANY Applle�tlen• INSTALLATION WILL SERVE; RESIDENCE❑ COMMERCIAL 0"'— OTHER❑ NUMBER OF UVINO UNITS; NUMBER OF Bf.�EDDRROOM$: NUMBER OF EMPLOYEES: EP CHARACTER OF SOIL TO A DTH OF 3 FEET; Si[. PITMUMP SOIL CHARACTER; WATER TA131F DEPTH ACr eEPTUCTANKAIREASETRAP ❑TYPEIMFO ITL-M6A) 04•-(FtS—IcAPAcrTY 3060 6-4U NO.COMPARTMENTB PKOTREATMENTMAW❑ DISTANCETONEAREST: �j�/WEnLL f�0 <T_ FOUNOATION /L Fr PRQPMIYLJNE 150C) UFT STATION 11srzE TYPE OF PUMP rL` AND OR SEPARATOR IENCLOSED GMEM1 /LU P-T— G ffACHIHG UNE 13 NO.8 LENGTH OF LfNE6 DISTANCE TO NEA :WELLFOUNDATION PERTY LINE 1.lip r REST FILTER SED ❑WIDTH 40 2 F7-LENOTH-12j2Lf-rDEPrH G— DISTANCE TO NEAREST:WELL/��0 f'1 FOUNDATION /24> PROPERTY LINE_ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 69MAGE PITS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCETO NEAREBT:WELL FOUNDATION P'ROPERTYLINE 019POSAL PONDS ❑WIDTH LENGTHI DEPTH DISTANCE TO NEAREST;WELL FOUNOATIGN PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHE BAN JOAOWN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"ICERTIFYTHATIN THE PERFORMANCE OFTHE WORK FORWHICH THIS PERMIT 18ISOM,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUPDRNIA.- CONTRACTOR'S HIRING OR SUB•CONTRACTINO HAT IFIEB THE O;M IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM PENe WB OF IMANT MUST CALL 2+HOURS IN ADVANCE FOR ALL REGURED INSPECT'HONS. COMPLETE DRAWING BELOW. ;7 SIGNED X TITLE:l� PATE: G PLOT PLAN(DRAW TO SCALE)SCALE_ •to � 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED t. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND IMPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING CQVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOMMIO PROPERTY. .. - ...... .,.... - - - - - ., ....... :. _ :.....:. ... . .. :.. . ............... .. ........... . w ..: ... .... .. 'a..5. . .... .. .... .. .. .. ..,,. .. .� . ..;. .. �PIJE}1JGHf�.Al.Iti'SERYICES ...: :ENVIRONMENTAL HEALTH DNISION .... :.......:. .:.. .. . .............. .........:..........:...... ................,...: .. .... ............................ .... .... ......'.. .. ........... ... FOR DEPARTMENT USE ONLYY --- APRICATION ACCEPTEQ B -_ W� �� DATE: I✓ • ! AREA: i f TANK,RT OR SUMP INSPECTIO14 BY DATE ( ! FINAL INSPECTION BY �-L /L�� DATE ADDrnoNAL COMMENTS: 1 l�Cf I ACOOUNTINO ONLY: AID/ FACT PIICODE FEE INFO AMOUNT RUAITED HEC ICASH REC BY DATE $R I PERI T NU)BEI INVOICE Pup,Health Serv.•ERviro.174(3196)