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APPLICATION FOR LIQUID WASTE PERMIT 64-JOAQUIN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 9MI-M (2091408-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �I!1-'I��-'� 1-7 q (Complete In Triplicate) F' AFPLICATION IB HEMBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WOW DESCROED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER �BI-11110.3 ANO THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTALHEALTHDIVISION. JOB ADDREBSIOR AM# 1 L L ] -J C, // 4 f I CITY �yC �� V�J LOT SIZE •� OWNER'S NAME nnn�-� (O �1 �� ADDRESS PHONE CONTRACTOR r.'j- R l 1 P.It [ N Sy.:." ADDRESS � ��U�� f-( )v✓ C t' .�/ _LIC(7/.S L'I J 3 MONS � �J^ SUBCONTRACTOR ADDRESS LICA MORE TYPE OF SEPTIC WORN: NEW INSTALLATMN ❑ REPMRIADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED N PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEM TESTNI 1 I159r ANT _ AooSEeeen �VVI INSTALLATION WILL SENE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NLRMSER OF WHO LINTS: NUMBER OF BEDROOMS: HUMMER OF EMPLOYEEa: I�IU r, 0 2 2001 CIIAMCTER OF MN TO A DEPTH OF 2 FEET: �/ PTIGOMP SOIL CHAMCTER: WATER TABLE DEPTH SEPTIC TANK"FASE TRAP ❑TYPEIMrO _CAPACITY_ IO.COMPAREMEHYBAN I �r, 1 1 - I •V PRD TREATMENT RANT❑ DISTANCE TO NEAREST: WPI__ FOUNDATION POPERrY'LII UFT STATION❑ SIZE TYPE Or PUMP BAND OIL SEPARATOR(ENCLOSED""IMI LEACHING USE 0 NO.S LENGTH OF LINER j —el,` DISTANCE TO NEARBY:WELL IW ' FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:MLL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTII LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BNMM EJ V11DTN 3 c. LENGTH OEITII DISTANCE TO NEAREST:WELL Jch, FOUNDATION /I PHOPERfY UNE w DISPOSAL PONOB ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I NEMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:')CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOn WIIICII THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENBATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUN CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I @HALL EMPLOY PERSONS BUBJFCT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24)OURS IN ADVANCE FOR ALL REQUIRED INBFECTONS. COMPLETE ORAWINO BELOW. SIGNED X TIRE: DATE: Z 'UIf If I L ROT PLAN(DRAW TO SCALEI SCALE 'LB 1. NAMES OF STREETS OR ROADS 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 OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIVB OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYS,AND WMXB. THE PROPERTY OR ADJOINING PrOPERTY. r CA R r C_ C/ l ��Iy FOR DEPARTMENT USE ONLY APRKATION ACCEPIE BY t✓ DATE: AREA:_1q TAME,FIT OR SUMP INSTION L DAIA / F/� FINAL IND CTION DAT ADDITIONAL COMMENTS: T ACCOUNTING ONLY: AIDS FAC# PE CODE FEE INFO AMOUNT RFMI I TEO CHECK( ASH RECEIVED BY DATE M IPUMT NUMBER INVOICE# 21 F2 r ,, 2-