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I II i +IIQUID WASTE PERMIT JQ{Q17M ILy^ S COUNTY PUBLIC HEALTH SERVICES Cp�� f 3� H�1,�i1 l IRONMUEkTAL HEALTH VISION 40A',af T/Y, ILII ROS; � �y 0 atlgltdl } 'SAN JOAOUIN ST4 S TON.CA 96201 ��ji �' (209)498.3428 ��rA l�fl i)At7y ' � aH NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED .- Slr {`,iy�� (Complete in TR41iwtB) p 'L 'IIFPl1CATgV IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDroR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE N COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9 1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRDNME TAL HEALTH DIVISION. JOB ADDREssron AM# O. ✓ F 5-o ISO, •Txlt c 4 8 t,yCl. CRY &L LOTsI- OWMEWS NAME /V,'G L/-A a ADDRESS f/� MONE— CONTRACTOR��f I7CNv ��N ADDRESS 60'rW gG.)e4vM �C�'/ • - uCE /PHONE ".I-Z41 J SUBCONTRACTOR ADDRESSyy�� LIC/ wow-- TYPE Of SEPTIC WOM: NEW INSTALLATION❑ RFPABVAOOTNON IBI DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEVER IB AVAILABLE WITHIN 700 FEET OF BWtDNO,) PRC TYTHI I 1 MOW MANY APMIaBwI/____ INSTALAT)ON WILL SERVE RESIDENCE Y COMMERCIAL O OTHER❑ .NONOSE-OF UVING GNTTS: / Nuys Bl of KEMOOMS: NUMBER OF ELRPLOYM: CHARACTER OF EGR TO A DEPTH OF 3 FEET: kelely PFTISUMP STIR CHARACTER:-"eVd"I&Clf WATER TABLE DEPTH SEPTIC TANIUONEASE TRAP ZITYPE.MFO F'YF CA:T CAPACf1Y AO C NO.CGEEPAPETM.-NTB f IPG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL 3 n T FOUNDATION :Z O PROPERTY U E }`O UFT STARON❑ — TYRE OF PUMP SANO OIL SEPARATOR(ENGLOBED SYSTEM) LEACHING LINE ❑ NO.A,LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUHOA'l PROPERTY 111E FILTER BED ❑WIDTH LENGTF' DEPTH DISTANCE TO FEAREST:WELL FOUNDATION PROPERTY LINE ^ MOUNOm ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WEU FOUNDATION PROPERTY LNE SEEPAGE PTS ❑DEPTH SIZE_ NUMBER DIbl ANCL TO NEAREST:WELL FJUNDATION PROPERTY LINE SLSAPB V\YIOTN LENGTH �`J�DEPTH 9*�" pb•TANCE TO NEAREST:WELL 614-I -FOUNDATION e' PROPERTY UNE /f DISPOSAL PONDS ❑WOTN LENGTH _DEPTH DISTANCE TO NEAREST:WELL___FOUNDATION PROPERTY UNE (/ I HLAMY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE W W WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES AND STATE u S.AND RULES \ AND REAWATIONS Of THE SAN JOAQUINCOUNTY.HOMEOWNER OR U.^.ENSED AGENT'S SIGNATURE CERTIFIES THE POLLOWNG:'I CERTIFYTHAT N THE PERFORMANCE OF THE VOOHIL FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN-d COMPENSATION LAWS Of CALIFORNIA.' CONTRACTOR'S HSOHG OR SU"ONTRA-TING SIGNATURE CERTIFIES THE FOLLOWING:.I CERTIFY- IAT IN THE PERFORMANCE OF THE W'OPK FOR WHICH THIS PERMIT IS ISSLIED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUYT CALL 24 MOURS IN ADVANCE FOR ALL AEG UNED INSP TIONIL COMPLETE DRAWING BELOW. SIGNED X ` '� TITLE:_ DATE: ROT PLAN IDRAW TO SCALE)SCALE -m 1.NAMES OF STRLLTS OR ROADS NEAREST 10 OR BOUNDING THE PROPERTY. A.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. \ O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUPES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON / INCLUDING COVERED AREAS SUCH AS PATIOS,DHIVEWAYS,AND WALKS. —= THE PROPERTY OR AOJONNO PROPERTY. ` G L U ....... ... .:.......... s. ry =7 J ..........:...:.... es ........ . .... ... en Z ....... . ..... . . w�L! APR '4 1996: O'AfIRO NIMEN•.AL F-AlTH Utvf5lc;,;, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA; TAN(•RT OR SUMP IN—CTION BY DATE I l FINAL INSPECTION BY r�o-V DATE / ADDITIONAL COMMENTS: (yam ACCOUNTING ONLY: AID* FAC/ t'2_ RE CD'JE F AMOUNT REMITTED CHECKOCAAH RECEIVED BY DATE OR I PERMIT NUTABEA INVOICE/ d 7 Q