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APPLICAIIWkFOR LIRUID WASTE PERMIT SAN JOAOUIUNTY PUBLIC HEALTH SERVICES ENVIE_..MENTAL HEALTH DIVISION 304 EAST WEBER AVENUE:,STOCKTON,CA 95202 (209)468-3420 RUN•REFUNDAKE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TIIplicedl APPLICATION 18 HEREBY MADE TO THE BAN JOAOUFN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 10 MADE IN COMPLIANCE WITH SAN JOAD001 COUNTY DEVELOPMENT TITLE.CHAPTER 9-1140.3 AND THE 67ANDAIFl8 OF SA1FNI JJOOIAOUFN COUNTY PUBLIC HEALTHY SERVICES,ENVIRONMENTAL HEALTH DIVISION. - JOB ADDRESWOR APNP 03s �SL �.,11 J J,�U-+ CHy Mci f 7 LOT WE L?)y Akre OWNER'S NAME�er+Torrcs, n2rftme_IAI'I11t1'U ADDRESS,IDD f'IRII'I sr�$I Helena.CA PHON -1 cDNTRAcroRCOhDay1�2 EAtI� Tec h1?Vf0g1 CS ADDIE58�d1$Ff k6h&5+0rdL3 StC-T irkf°I%I--- R /ry]+ '}-br✓-1$ SUBCONTRACT-R on r l ADDRESS�1 LICIT YrD a. 17f PHON 0-10i Oal I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAiRMOO1TION❑ DESTRUCTION❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) FORD TESTNI 1 I HOW MANY 4 - i llpen• I INSTALLATION IMLL SBNE: RESIDENCE❑ COMMERCIAL A OTHER❑ NUMBER OF RIVING pHBTaI�_NUMBEROFBEDROOMS: NUMBDI OF F)IePLOYEEs: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: I+I - PFTMUMP BOIL CHARACTER: WATER TABLE OEPTHa e_` SEPTIC TANK/OREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS PKO TREATMENT RANT 11 DISTANCE TO NEARtSY: WELL FOUNDATION PROPERTYLINE ERT STATION 0 9ZE TWE OF PUMP SAND OIL SEPARATOR IFNCLOSED SYBTEMR LEACHING LINE ❑ NO.i LENOTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPETNY LINE ALTER BED ❑WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE O< MOIRIDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.WELL. POUNDAYION PROPERTY UNF SEEPAGE PITS C]DEPTH SIZE NUMBER DISTANCE TO NEAREST'WELL FOUNDATION PROPERTY LINE [� SUMPS [IWIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS 0 WIDTH LENGTH DEPTH DISTANCETO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AM RULES -L_ ANDREGULATIONGOf THE GAN JOAONN COUNTY.HOME OWNER ORUCENSEO MEN'S GIONATURE CERTIFIES THE FOLLOWWO:'I CERTIFYTHAT NI THE PERFORMANCE OF THE WORK FORVAM" S>, TWO PERMIT IS ISSUED,I=NOT EMPLOY ANY PERSON IN OUCH A MANNER AS TO BECOME SUSIECT TO WOFKMAN'e COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HNVNG OR C1 SUS-CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWINO:Y CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 GNAL.L EMPLOY PERSONS SUBJECT TO O WORKMAN'S COMPENSATION LAWS DOFF CALIFORNIA.'THIE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REWARIS, ED ENKI OPECTNI.COMPLETE DRAWING eELOW. SIGNED x_ F!`^ // _ _ TITLE:�ro i 0 c r I l O x 4 IF r-- OATEN PLOT PLAN IOMW TO BCALEI SCALE /_ _•OPeao a p 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATIONOF NORSE SEWAGE DISPOSAL SYSTEM OR PROPOSED "T 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, ESI XPANON OF SEWAGE DISPOSAL SYSTEMS. [W 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EOUBTSNO AND PROPOSED STRUCTURES, E.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOGINO PROPERTY. "DA �r N� ��..... � � W,A A! 27---1998 fi.. __ . ....rn......, ... .... ...; �3: ...�. _rte.. ..... ,.... . ...., sn•� 2 nrau�ly cgUrvn,... ' 2_ EA7 L RUIC&5... a. rivlRr MrHvrn�R ...... - .--..... ... .,,.,� A ihi L'IV'S ... i.......i...ti„ .. .. id ... __ .. - 1 ashw�... n ek R .... . ��re .. ... ... .... ... y FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY DATE: APLA: TANK,FIT On SUMP INSPECTION BYII C / DATE !^FMA..INSP:CTION BY I / I DATE 9 / ADDITIONAL COMMENTS: !I- Sr i t ' ^'-C As L" w ♦ f"i y ! 4 1' - a'iI n Q,�'C - �" CF" c✓trA.� o/r S � wrlE a r�Trr+I o .. w�a<r e ACCOUNTONO OTIY: ARO/ FAC! FE CODE FEE INP- ANK)UNT-11ED C11ECl/IC RECE3MFD SY I ATE SRI PERMIT NUMBER INVOICE E Pub.Health Serv..Errvlro.174(3198}