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APPLICATI" 'FOR LIQUID WASTE PERMIT SAN JOAQUit LINTY PUBLIC HEALTH SERVICES y _ ENVIROIRMENTAL HEALTH DIVISION ` 304 EAST WEBER AVENUE,STOCKTON,CA 95202 c" (209)468-3420 . NON-REFUNDABLE PERNIT EXPIRES 1 YEAR FROM DATE ISSUED IC..FktB IR TFlpk-t-) MTLICATK)N 19 HEREBY MADE TO THE SAN JOAWN COUNTY FOR A PERMIT TO CONSTRICT AND/OR WSTALL TIIE WOW DESCRBED.THIS APPUCATWN IS MADE W COMPUANCE WITH BAN JOAOUN COUNTY DEVELOPMENT TTTLF.CH�fAFTTER 9-1110.7 MID TME St ANDARDS OF SAH JOAOUIN COUNTY MmIL/C HEALTH SERNCEB,ENVIAGHMENTAL HEALTH DIVISION. 18 ADORES9/OR ARTIF ✓ CFTY� LOT SIZE J j �A?IER'S NAME ' ADDRESS - CONTRACTOR ADDRESS �� RIOIIE 10 CONTRACTOR ADDRESS LICE RIONE EPE OF SEPTIC on. MEW(Mei AIUTWX 11E➢ANVAOpTWN ❑ DUTRVC IK)N❑ WO SEPTIC SYSTEM PERMITTED IF PUBLIC.SEWER 19"ARABLE WITHIN ZOO TEFT OF BUILDING.) PFRC TESTI�I 1 1 NOW MANY // APp►o�tm ETAO.ATWN WILL SFRVE: M.-WE❑ COMMERCIAL❑ OTHER m ll JMSER OF UVINO VISTS: -UMSIA DE BEDROOMS: NUMBEA OF EM OYELS: --HARRACTER OF SOIL TO A DEPTH OF J FEET: ,../PFTIS,U/M�P'-S-OIIL CHARACTER: �J�� WATER TABLE DEPTH SEPTIC TANK)oRLASE TRAP 'VT,,,.��+�L/ co �"'�` CMAC I Kl6 NO.COMPAFTTMENT. "G TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL � / -ZUNDATK)N 1/0 PROPERTYLOW LIFT STATION❑��l��T�SStZE TYPE OF PUML��,[')� SAND OR SEPARATOR(ENCLOSED SYSTEM / _ACHI-ME p NO.A IE-TH OF UNE.�-.! ABTA-f TO NEAREST:W'ELL�FOUNDATION //J � PROPERTY UNE�6 FILTER BED ❑WK)TH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PFIOPERTY UNE MOUNDED ❑WIDTN LENGTH DEPTH DISTN E TO NEAREST:WELLFOUNDATION PROPERTY LAZE- -.m FAS ❑OEM" S2E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LLIE ,NPS ❑W TH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE � SAL PONDS ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - I HEREBY CERT"THAT I HAVE PF&PAWD 1HIS APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WNH SAN JOAOUW COUNTY ORDINANCES AND STALE UWS,ANO RALES K)REOULATION9 OF THE SAN JOAO S4 CoL .HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTNES THE FOLLOWING:-ICERTEYTHAT W THE PER FOA MANCE OF THE WORK FOR WHICH IIS PERMIT m ISSUED,I SMALL NOT EMPLOY ANY PERSON W SUCH A MANNER AS TO BECOME SUBJECT TO WOW MAN'S COMPENSATION LAWS OF CALIFORNIA-' CONTRACTORB WN OR MCONTRACT WG SIONATURE CERTIFIES THE FOLLOWING:Y CERTIFY THAT W THE PERFORMANCE OF THE WORK FGR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO . WMAWS COMPENSATION LAWS OF C RMA.�TIE APPLICANT MUST CALL 24 HOURS 8R ADVANCE FOR ALL 1R�E/GLA,R�ED,/t�Ne�PECT�IONS. COMPLETE DMWMIO SIGNED X V �1/ •l-s/ TITLE `�GG"/ DATE: PLOT RAN(DRAW TO SCALE)SCALE_ NAMES OF STREETS OR ROADS NEAREST TO OR SOUND-0 THE PROPERTY. ♦.LOCATION OF HOUSE a AOE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE AK)PERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 1. DIMENSIONED OUTLINES AHD LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6 OCATION OF WELLS WR1SN RAD0./8 OF ONE HVNDIIED FIFTY FT.ON 11ilSIG COVEIE SLICM A8 PATL08,DISVEWAYB,AND WALKS. PERTY OR ADJORMKI PIK)PERTY. rj SAN 0 IIII PUBLIC HP✓LITM SEi'NK.GS _ :.. `17 .... EHVIFIONMEH7AL HEAl7H _ OR DEPARTMENT VEE ONLY l� UP APPLICATION ACCE/'fTo BY_ G T DATE: 1 ,.�� § NEA'��J/ SNC,PR OR SUMP NSPECTIOH BY DATE I / FWAL WSPEC - - EKi I 'CRATE / /TT�/ HJ/TIONAL COMMENTS' ACCOUNTING ONLY: RADE FAC/ PE CODE FEE INTO OME ROWITED CHECIU N NEC BY DATE ml T MUMMER INVOICE -21 .60 oeS's4-l Pub.Health Sew.-EDviro.174(3/96) 3q-2) ` n �-F'9 • o uy s n