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APRLICATION FOR LIQUID WASTE PERMIT I' N(,,QUIN COUNTY PUOUC 9FALTH SERVICE" ENVIRONMENTAL HEALTH DIVISION P.O. BOX 3%. EAST WEBER AVENUE, STOCKTON, CA (2091 488-3420 ," A. '1, NONREFUNDABLE PERMIT EXFIr1lLAX U00M.D.A.TE ISSUED (CBmplalo'bi TIIP1e1116) �ti,..'.t ANON IB HEREBY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT A 1R INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE BART Ary l,.` LIQ COUNTY DEVELOPMENT VILE,CHAP 9-1 10.3 AHD THE STAN ARDS �Fy BAH J A UIN COUNTY PUBLIC MEA 4ERVICEB,E VIRONMENTAL HEALTH DIVISION: �ADDFIESSIOR APNF. / �' A• r ' ��.�-�" LOT SIZE' �} ER'S NAMEADDAEB fff PHONE 1 !%ONiAACTOR I AbDAEBB I °' UCf r+ } J :a I � � PHONE, .( � A �SUII CONTRACTOR ADDRESS i' UCf PHONE . Is TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAJPJADDITION ❑ DESTRUC710N :+y IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TEST(f)I ]NOW MANY `i' AOdlo�tlan f INRtALLATIGN WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER 0 IFUMBER OF UVINa v/11Te: NLx+iISER OF SEOROOmw NUMSER OF EMPLOYEES: ' CHARACTER OF SOIL TO A DEPTH OF O PEST: htisumP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANWOREASE TRAP TYPE/MFO CAPACITY NO.COMPARTMENTS PKC TREATMENT PLANT 0 DISTANCE TO MEANEST: WELL__-- FOUNDATION PROPERTY UNE r, UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR{ENCLOSED SYSTEMI LkAbNNO UNE 0 No.Al LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Wim RED ❑WIDTH LENGTH bEPT-9 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 'MoiINow ❑WIDTH �•LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE it&0E FITS ❑I DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE �UH1PS L3 WDTH LENOTH bEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 'V ., blibOR1AL PONOS ❑w1oTN LETlGTIf DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PfgPERTY UNE M.�°1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPIJCATIDN AND THAT THE WORK WILL 8E DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ."±AND REOULATIONS OF THE SAN JOAOU1N COUNTY,HOME DVYNER OR LICENSED AOENT'S SIONATUPE CERTI IES THE FOLLOWING:'I CERTIFY THAT IN THE PEAFORMANCE OF THE WORK POA Wl*CH . �y;4H18 PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER As TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIISNG OR �h'5,'' &CONTRACTINO SIGNATURE CERTIMN THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PEASONS SUBJECT TO ,, WORKMAN'S COMPENSATION LAWS OF CAUFOANIA.' THE MPUCAN MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. ilgtlNEO X � TttLE: (.'�J t' 1 '-r•.+ r _ --DATE: , • E.,„ PLOT PLAN(DRAW TO SCALE)SCALE •to A#I£S OF STREETS OR ROADS NEAREBt TO OR BOUNbINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBEP LpX OF THE PROPERTY,WITH DIMENBIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, NEB OUTLINES AND LOCAtION OF ALL EXISTING AND PROPOSED 8TRUCTUREB, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORED FIFTY FT.ON , LUo1►10 coVETtD AREAS 6UCH Ad PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. - i - ., .. - ... r .f. ....4r ................., i ........:.... .. ., .., ........... ........ gg .. .......... 11, .............. ................ : .4: �: ,a.:....................:...... ... r r I 1 i : I, AYME1nIT J , .. ..... IM� SFr UG-T-2 5 T , 7• pl UA I 0 ... 'Ue�1C HEAL TI!SE VICES ..... ....:. ...,....., } ;............ ................. ET4vIPbNME�fTAL FitALTH DIVISION..,.:.....;..,.., 3 ..................:............:.......:.......:... :...... ...................... :......:........... .•,.t FDR DEPARTMENT USE ONLY ^' tl�. r • bAT[�: AREA: 1KINACCEPTEDBY - ++fit l},0l1 SUMP INSPECTION BY ATE�� FINAL INSPECTION BY DATE '6OMMENTB: ONLYI Awl FACE INVDIES FEE INFO AMOUNT REMITTED �HECKf�ASH RECOVED BY DATE Sit l PE NUMB `l -7x. V U IS) >-7All " ;ri I