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APPLICATION FOR LIQUID WASTE PERMIT <br /> ,dN'JOAQUIN COUNTY PUBLIC HEALTH SERVICEr <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX W8, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.988 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M TrlpUub) <br /> APPLICATION 18 NEWBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMMANCE MTN BAN <br /> JOAMIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 O THE BTANDARDB/9(/F BAN JOACMIN CO NTY PUBLK:HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR AAMiF 1 //�� / C CITY ' 1 C// ,Y� --JLOOT{&Z���!/(L� <br /> OWNER'S NAME`�,/I�- �l 'C- —e ADDRE88 (70^ /'/ / 1 - di;2? PHONE <br /> CONTRACTOk-,M04 499 J�,�T1C.� ADDRESS (`( �.. 0//LJ(�l[�/1�,�1 ��IC Me gpNEx/63-5��3 <br /> SUB CONTRACTOR ADDRESS Lice PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION RERAIRIADDITION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 30D FEET OF BUILDING) FERC TESTW I 1 HOW MANY <br /> Applla loR l <br /> INSTALLATION WILL SERVE: RESIDENCE 0 COMMERCIAL ❑ 7 OTHER 11NUMBER OF"NO UNITS: /I NUMBER OF BEMOOMS: J NUMBER OF EMPLOYEES- <br /> CHARACTER OF SOIL TO A DEPTH OFF 33 FEET l4miBUMP SO,,L_CHARACTER. ( `• WATER TABLE DEPTH h9O / 'f <br /> T N1UOREASE TRAP MF.TYPE/MM R/Y�(.1(� � ��J�1 CAPACITY Q YJ NO.COMPARTMENTS <br /> �X <br /> f/FATMdT RANT 0 DISTANCE TO NEAREST: WELL_Z+ FOUNDATION r;�5 ' FWKPTY LINE <br /> LIFT STATION❑ SIZE TYPE OF PUMP 4 /SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE ]"NO.S LENGTH OF LINES �-'7 /c-Q�PF L�G DISTANCE TO NEARFBT:WELL�Q i FOUNDATION S ' PROPERTY UNE <br /> FILTER SED ❑3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELI FOUNDATION PROPERTY LINE <br /> MOUNDED ❑MOTH LENGTHLL DEPTH DISTANCE TO NEAREST:WEFOUNDATION PROPERTY UNE <br /> iFEPAOE N _TS DEPTH /2�SIZE Jam•E NUMBER DISTANCE TO NEAREST:WELL5-40' FOUNDATION Z S 1 PROPERTY UNE <br /> BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORIL WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS FEW T IB 186 ED,I SHALL NOT EMPLOY ANY PER90N IN a CH A MANNER AS TO BECOME SUBJECT TO MRKMAN'B COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNG OR <br /> SUB-COM IT'S SI ATURE C RTIFIES TH OLLOMNO: •I IFY THAT IN THE PERFORMANCE OF THE WONL FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPEN6A W OF A IFO IA.' N UST CALL U HOW IN ADVANCE FOR ALL REOUINEO INSPECTIONS. COMPETE DRAWING BELOW. <br /> SIGNED% t TITLE: L LVL* R DATE: <br /> POT PAN(DRAW TO SCALE)SCALE 'In W <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. •. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROM SED <br /> G <br /> 3. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. '•J <br /> J. DIMENINCLUDING <br /> CO OUTLINES AND SUCH <br /> P IO ALLDRIVEWAYS. <br /> EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON C <br /> INCLUDING COVERED AREAE BVCH A8 PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> L <br /> C/i 7 <br /> r <br /> }(olt t P <br /> R <br /> PAYMEN <br /> (so ' Ir JUL 141998 <br /> SAN JOAUILIN COUN fti' {I <br /> -- PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OMSK), <br />