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APPLICATION FOR LIQUID WASTE PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV,, ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 _ NOR-REFUNDARIE PERMIT EXPIRES I YEAR FROM DATE ISSUED cc-v36tt I.Tripr—t6) AprUCAnOH IS HERESY MADE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AND,OR INSTALL THE WORK DESCMBED.TMS APPLICATION 46 MADE IH COMPLIANCE WN"BAN JOAQUIN COUNTY DEVELOPMENT TILE CHAPTER D-1110�3f ANO THE STANDARDS OF SAWN JJOOAOWN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH WM N. JOS ADDRESSIOR APN. 'a4,Lx ,4--,1(1.�E- �fI�YW 1 �ILL•i/7J.9N1P? ��/�CRY %.':.l) LOT BQE�.l- OWNEA-S NAME .✓4 iy//- �7T.{LIQ/N7�_y- ADDEIES9 I(� -t) �YI'w✓ YY� PEgNE/��(1-UI!<2 CONTRACTOR / ��/l � AODRE55 jl%mclr, :'/ &,e!e, -c.-�i L,l.-T�YG RIC/�+. YG'YS6 PHONE SVR CONTRACTOR ADDRESS LIC. RHONE TYPE OF SE WORK: NEW INSTALLATION❑ REPNR/ADDITION Q DESTRUCTION❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVARABLE WITHIN 200 FEET OF BDILDIN0.1 RRC TESTI•)1 1 HDW MANY APPA—. -- MSTALLATION WNL SOME. RESIDENCE V COMMERCIAL❑ OTHER❑ , NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF D FEET: 1/,_i� ,}PN/SLIMP SOE CHARACTER WATER TABLE DEPTH �40 SEPTIC TANK/aE�ASE TRAP ❑TYPEAMFO �V�� 1 4'RCAPACETY NO_COMPMfMENTS ►KO TREATMENT FLINT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LME UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR ENCLOSED SYSTEM) _ r• LEACH!"UNE LST NO.A LEHOTH OF LINES I-yV &A LI H'fes.INSTANCE TO NEAEST:WELL=1 FOUNDATION � PROPERTY LINE 7 FILTER RED ❑WIDTH LEMaTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE M011NOFD 0F�WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE mt UDD H _K E Jam" NUL48ER I OISTAHCE TO NEAREST:WELL_I;2y' FOUNDATpN--.;E-_PFAPERTY LAE 50 SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATON PROPER"LINE r DEPTH DISTANCE TO MEANEST:WELL FOUNDATION PROPERTY LINE dsrotAL Po-ot 11 WpTN LENGTH 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN—AMIN COUNTY OIRDIIANCES ANO STATE AWB,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWHER OR UCENMD AGENT'S SgNATUPE CERITIES THE FoLLOWMO:I CERTIFYTHAT N THE PERFORMANCE OF THE WORK FOR—H WII THIS PETMNT is ISSUED.1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WOIKMAR'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S N"M OR .: CONTMCTINO SKNATW%CERREES THE FOLLOLYBRR:-1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SIAL EMPLOY PERSONS SUBJECT TO r WORKMAN'S COMPENSATION LAWS OF CALIFORNIA'THE APPLICANT MUST CALL 24 HOW M ADVANCE FOR ALL HEOURED p1SPEC710Nt.COMPLETE MAYN BELOW. L � SIGNED% TITLE: DATE: PLOT PLAN IDRAW TO SCALEI SCALE -M 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOMO THE PROPERTY. 4.LDCATION OF IIOtM SEWAGE DISPOSAL SYSTEM OR PROPOSEO EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2.OUNE OF THE PROESRTV.VAM DIMENSIONS AND NORTH DIECTION. T 3.DIAHENRONED OUTUNE6 AMD LOCATION OF ALL E%ISTMG AMA PROPOSED STRUCTURES. S.LOCATION OF WELL WRI1111 RAdUt OF ONE IIl1NORED TREY R.ON .N(.2l/DIIO COVD AREAE SUCH AS PATIOS.DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOIIHO P/tlPERRY. OIE7n� vil PAYMENT RECEVED IU T ✓l' ....... x : �-! �- DEC 91997 ;_... w� '. . SANJOAQUINCQUNTY ......... ...... — ENVIRONMENTAL HEALTH DIVISION FOR DEPAITMEW USE ONLY �T CDATE: AflEA' APPLICATION ACCEPTED BYI/Giu�_ DATE Z/ y l 17 TANK.PIT OR BUMP MSPECTION BV DATE I I FINAL INSPECTION 8Y ADDITIONAL COMMENTS: ACCOVNilNO ONLY: NOP FAC. PE CODE FT NFO AMOUNT ram IT Cl/ECIV ASH REC SY DATE 6R/IEMAi-LIMBER INVOKE. Z O I I S Y,)-`7 U 3 78 9 Pub.Health SON.-EJrvirO.174(3/96)