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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN .qRUNTY PUBLIC HEALTA"3KERVICES <, ENVIRONMENT t.'DI)OSION 304 EAST WEBER AVlAOGI(TON, CA 9,921 ;_'. (209)468.3�i6 NUN-REFUNDABLE PERMIT EXPIRES 1 YEAR FA'CAT'09IT'�YSSOEO`� . 1=plots In TOPIWt51 ib APPLICATION 18 HEREBY MADE TO THE BAN JOA WIN COUNTY FOR A PERMIT TO Cooe�'IBSBEMM�/ccT ANDMR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN .OAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH"AMES,ENVIRONMENTAL HEALTH DIVISION. `! JOB AGGRESSOR APNI `II Lrl/ 2 Sc-- v+� CRy_Ad '-LY!A LOT SIZE_ O M,ER'e NSM CHIJN/Y"/L- SNL. n/ ADDRESS CONTRACTOA15--'11P,Q1ShNt-:;t Se-W5PHONH ?532 /Z. ApDREfis4CC'C1 µy1 SUS CONTRACTOR L� � �� ADDRESS LIC/ RHONE TYPE OF SEPTIC WORN: NEW INSTALLATION ❑ REPAIR/ADDITION DEITRUCTON❑ [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PSIC TESTRI 1 I HOW MANY Gam'� AFPMsYFn S INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER .�<.wH/fry L �'1` // F� NUMBER OF LIVING U IMS NIAMSM Of SE MOOMS; NUMBER OF EAPLOYEER: CHARACTER OF 601E TO A DEPTH OF]FEET:K AN!'J PR/BUMP 601E CHARACTER: S IO Nb WATER TABLL DEPTH SEPTIC TANXK EASE TMP IATYPER.HFO . )L L-B�T' CAPACT' NO.COMPARTMENTS PEO TREATMENT PLANT❑ DISTANCE TO NEAREST:WELLYY FOUNOATIdW /n/ PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PRIMP BAND OIL SEPARATOR IENCLOSED SYSTEM) •^4 s LEACHING LINE ❑ NO.S LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER SED ❑WIDTH LENGTH DEPfN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNF MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEFAOE RTS ❑DEPTH SIZE NUMBER NOT �AAN�WT/O�N[SMST:WELL FOUNDATION /B PROPERTY UNE SUMM WIDTH ISNOT t DEPTH �' / IITBTANCE'�O NEAREST:WELL r.-2, FOUNOATgN 4fV I PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Of DONE IN ACCORDANCE\YTTH SAN JOAOUIN COUNTY ORDINANCES AND STATE)AWB.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIO PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME BUBJECTTO WORKMAN'S COMPENSATION)AWB OF C/JJPORNIA.- CONTRACTOR'S HIRNO OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POO WHICH THIS PERMIT IS ISSUED.I SHILL EMPLOY PERSONS SUBJECT TO WORKMAN'S CC0MPEN�SAATK)N LAWS OF CALI�MRR�NIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALLREQUIRED INSPECTIONS. COMPLETE DRAWING/BELOW. SIGNED% /ll�-/�/I/"—( -Y� .-i�0> -71' :j-3� - TITLE: /�F OATE:AT PLOT PIAN DRAW TO SCALEI SCALE -In 1. NAMES OF STREETS OR SCADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND P RASED STRUCTURES, S. LOCATION OF VJE118 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WAITS. THE PROPERTY OR ADJOINING PROPERTY. yy 1� r . . r9g� Q d f.. 1J41vLn� _ G W'4in.kTY . .. a ho 7c4 4 vW W ¢*Ak.. _ O 1 N LL fit LLS .' 11 r 1 1M�6.INC. q1 _ TAR . . . ILEI O - U IL Si e VIS' I3 Z. 81 �. ( ////' /• ....FOR DEPAPTMENTUSE ONLY `4 I APPLICATION ACCEPTED BV _�f DATE. A AD TANK.PIT OR BUMP INSPECTION BY DATE 1 INAL INSPECTION By /. ➢A'x ' V G' 6 / ADDITIONAL COMMENT S.�A)V, e k ,' _ (rT p ACCOUNTING ONLY: AID, FACT �RI,S `,lJl��j( _Rr�ITT�Cy/J(I N'W PE CODE FFE INFO AMOUNT RFT.IIRED CIIEC CASH RECENFD BY DATE ..� B11I PERMIT NUMBER INVOICE P N Z O L O y Q 1-5A Pub.Health Se, -Enviro. 174(3/96)