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� APPLICATION FOR LIQUID WASTE PERMIT wr <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -/- .V(v <br /> (Complete In Triplieetel E j i <br /> APPLICATION IB HEREBY MADE TO THE BIW JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ARDDR W STALL THE WOR(DESCRSED. THIS AFIMCATIDN IB MADE IN COMPLIANCE WITH BAN <br /> JOAQUW COUNTY DEVELOPMENT 8-1110.THE STANDARDS OF iAN JOAOUIN COUH{JA PVBUCCHEALTH SERVICES,EN EMK REAL H DIVISION,OT SIZE '- C <br /> JOB ADARESBgR AMR L{ !/l/7✓/'"�Vf�L/G/•A 12.2 s(v/'/ `I�,I'ry[_f�A <br /> OVMER'S NAM rTN�O'L/ �JTl�9 <br /> ADDRESS� J fwe J PHONE <br /> CONTRACTOR�f/A/f/�LX�" ADDRESS MR 7J/ ( RHONE <br /> SIM CONTRACTORS/V�,J r �� ADDRESS � C ( Gam`[ 5(4-Me -[ �j RpNE •A' Y <br /> TYNE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDIT10N ❑ DEITRUCTO <br /> NO SEPTIC SYSTEM PERMITTED IF RISLK.SEWER IS AV ILABLE WITHIN 200 FEET OF BUILDINGA FRO TESIM I I HOW MANY <br /> ApPllatlen I <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER 11 <br /> ff'WET <br /> 7NOUMTSNUMBER OF SEDROOMS. RUNNE 1 DF 1MMDVFf1:60RToA DEPTN Of]FEET + /BUMP 601 CNARACfFA�r WATER TAmE DEPfN REAAE TRAP ❑TYPEJMFO CAPACRY I �n NO.COMPARTMENTS <br /> PLANT❑ DISTANCE TO NEAREST: WELLS D FOUNDAMN�_ RIDPE u*SE O _ Z <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OR 6EPARATOR ENCIAeED SYSTEM) <br /> , <br /> LEACISNO UNE ](JJNO.M LENGTH OF LINES DISTANCE TO NEAREST:WELL�I !;'FOIRNIATpN Y0 • FROFER1Y LINE "l nCD / <br /> FILTER SED /❑—WIDTH LLNGTH DEPTH DIWANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED It= <br /> ❑y0 W TH LENGTH <br /> ��DEPTH� /�/. DISTANCE TO NEAREST:WELLFOUNDATION FROPERTY UNE <br /> SEEPAGE FITS b DE9fH ROE C71'f NUMBEn y-___DISTANCE TO NEAREST:WELL�FOUNOATVON I'O A PROPERTY UNE <br /> own WIDTH LENGTH DEPTH '-I DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLHCATION AND THAT THE WORK WILL M DONE IN ACCORDANCE WITH SAN JOAWIN COUNTY ORDINANCES AND BATE LAWS.AND RULES <br /> AD REGULATIONS OF THE SAN"AWN COUNTY.HOME OWNER OR LICENSED AGENT'S MNATURE CERTIFIES THE FOLLOW WU:'1 CERTIFYTHAT W THE KAM MANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IT ISSUED,I SN NOT EMPEOY ANY PERSON W SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN-6 COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S MANI)OR <br /> '- SUB{ ND <br /> SIONA CERTIFIES THE f0 RANO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 181SSUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WO MAR'S C PN <br /> AT WB OF NIA.' THE APPIJCANT MUST CALL M POUND IN ADVANCE FOR A^LL REQUIRED INSPECTIONS. COMPLETE DRAWING B�E(LTYOW. <br /> BRINED% TITLE: '1 DATE: <br /> ROT PUN DRAW TO SCALEI SCALE 'Ie <br /> 1. L.I. .,1012.NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISRISA SYSTEM OR PROPOSED <br /> i. OUTUME F THE .WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISFOBAL SYSTEMS. ' v^^C^ITN <br /> G. dMEN813 LINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS NTTHIN RADIUS OF ONE IIUFDRIED�FS�FI O <br /> -" NCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAULe. THE PROPERTY OR ADJOWINII PIIDPERTY. RECEI <br /> r SAN JOAOUIrNAVLICE <br /> N <br /> PlIB!(GNEALT <br /> MMONMEN.Ttk.M AI,TH.D1. SIGN <br /> 01 <br /> �� (= <br /> NPS° 1A I <br />