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_ sa o "s APPLICATION FOR LIQUID WASTE PERMIT n `SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION L E COPY P,9. BOX 988, EAST WEBER AVENUE, STOCICTON, CA gm,LOUL (2091489-3420 NON-REFUNDABLE ERRIT EXPIRES i YEAR FROM DATE ISSUED (Complots in Tripikato) A';PLICATION IS HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OA INSTALL THE WORK bESCRISED. THIS APPLICATION IS MADE IN COMPI_I�6t3T:r:dtrd"'a r SFI JOAQUIN COUNTY DEVELOPMENT TITI.E,CHAPTER S-1 11 R.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ;f•ay A,f?3'TIIESRIOP+.At'NN.�_. / CITY A6ORE5S PHONE __ A -1r �- � 3-6393 ._AooREs� !L/ � �' � S uca PHONE !v_ ADDRESSUC9 PHONE I T":r nir SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION DESTRUCTION © 4140 SFI'TYf:,SYSTEM PFRMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 20D FEET OF BUILDING.) PGRC YEBTIa)I I HOW ApplimtIon m tl c3'A;.t.A.TION 4W-0 9 AVE: RESIDENCE 10 COMMERCIAL. I OTHER I�_-- -- ""'"'""'"'""-��'��--..•... !I OF I.IVINtO UNITA: ! NUM86TR OF BEDROOMS: µ_ NUMBER OF EMPLOYEES: ' 1 n F' �n_�,r;7'1'1�.Q!-,'4 t Tia A DFFP'fI OF^^377 FEET! 1 P}s��PLTISUMP SrAk CHARACTER:_`7�'�'�C WATER TABLE DEPTH Si PyM YANICIM.TA5[TRAP LJ TYNEIMFO —CAPACITY NO.COMPARTMENTS _ \ PLO TSLATMFW PLANE Cl DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE— . i UFT STATION 0 SIZE TYPE OF PUMP BAND OIL SEPARATOR tENCLOSED SYSTEM) LEACHING UNE UNE kW NO.B LENGTH OF LINES !-��O r DISTANCE TO NEAREST:WELL�f't FOUNDATION_PROPERTY LINE 7�`_� FILTER BED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 'Q MOUNDED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY UNE � I SEEPAOE PITS �DfPTH �B,ZE�_NUMBER_DISTANCE TO NEAREST:WELL�'�'t' FOUNDATION /�O PROPERTY uN€.�„ �_____- .� SUMPS ©WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE__ DISPORAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ___ i 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORT(WILL BE DONE IN ACCORDANCE WITH SAN'JOAQUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES , AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIES THE FOLLOWING-.'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHIP:H THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR i SUB-[ON'r (3 el URE CE HE FOLLOWING:'I C THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PfAMrr IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WO 'S CO ATI N FCA ORNIA.• THE AP CA MUTT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWINO BELOW. TITLE:_i�I'�+1 DATE: /d�Z PLOT PLAN(DRAW TO SCALEI SCALE 'Ln 1- NAMES OF STREETS OR ROADS AREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM Oii 2. MlfkINE OF TIM PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3, rIMF,NSIONE0 OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORED FIF I'f FY,�'N INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. I + : y -13sf ,. r'l��aLiC:HEr�ITI146 S�R'71 d „ p�+ Zvi .. OIL&)Jluy— ArPtIC:AT(ONACf.EfT-fbBY DATE: ✓ AREA: 2— _ C� I YANK,�'OR SUMP INSPECTION BY r DATE/ INSPECTION B DATE��I �!` ADDITIONAL COMMENTS: ACCOUNTING ONLY, AION FACN �....._�,�...�,_ ,.. PE COD£ FEE INFO AMOUNT REMITTED CHIC CASH RECEIVED BY DATE an PERMIT NUMBER INVOWE! 1J D3�871 .._.._._._.