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APPLICATION FOR LIBUIO WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE, STOCKTON,CA 95201388 (208)UR-3420 IIOB•REFUIIDABLE PERMff EXPIRES 1 YEAR FROM DATA ISSUfD ¢{IRPI{t{if TrFPMW APRJCATIDN le HEREBY MADE TO THE SAN Jo AOUN COUNTY FOR A PERMIT TO CONSTRUCT ANOJOR INSTALL THE WDAK DESCRIBED, THIS APPLICATION IS MADE IN COMPJANC£WAN SAN JOAOUN COUNTV DEVELOPMENT TITLE CHAPTER 8-1110,3 AND THE STANDARDS Of BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL`HEALTH DMeto, JOB AWNDOAESS/On Ao / C / OCT' J �.5,../��A N/ LOT SIZE OWNER'S NAME_ / ea CONTRACTOR 'J�e, J ��f�A0011ES6 �/D .�L-AItij i��• ucF�J/ .j�_PHONE S'�S-4t t7l SUB CONTRACTOR ADDRESS UCP PHONE- TYPE ONE TYPE or SFTM WORK: NEW INSTALLATION J3 REPAPUALNJRTION ❑ DUTIIIICTION .D tE,SYSTEM PEHMTTTED F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of aUILDN0.1 P91C Tb7hF T 1 NOW MANY \\ ��{{ APpSa�YsR S IN{TAIUTION WILL Bar,/K- RESIDENCE YQ COMMERCIAL❑ OTHER❑ NUtINIUM OF Uvwo LIMITS! NUMMIR OF/RADROOMS:,� NIS.MER OF Wmay I:"_T_ CHARACTER Of BOR TO A DEPTH OFp]F4E7:-1 O PITMUMP 000.CHARACTER:_ /�.�JJQ /Q WATER TABLE DEPTH �O FErnc TANKJdEFJUE TIIA► �U TYPEMfO_ I G CAPACTf `-7 LACI NO.COMPARTMENTS PRO TREATMENT RAW❑ DISTANCE TO NSAASST. WELL 1(-2 FOUNOOATION� S:�7'_ PIOpORY RINE/.S U LIFT STATION❑ 812E TYPE OF PUMP BAER OIL SEPARATOR(ENCLOBEO SYETEN" R LEACHING UNE ❑ W.S LEPIOTH OF UNE7_ DIRTANCE TO NEAREST:WELL WJIANDATIOH pROFERTY LINE RLT61■W ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOLNww ❑WIDTH LEJGTH _DEPTH DISTANCE To NEAREST:WELL _FOUNDATION PROPERTY LINE 7C1 SSDAOE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:NEIL__FOUNOATIOM PROPERTY LIM I V SUMPS Q WIDTH 2 lENarH_/ DEIN f. Z� DISTANCE TO NEAREST:WELL ZQ-0 PROPERTY LINI 2a OISPOIAL PONOS ❑WIDTH LETDTH DEPTH DISTANCE TO NEAREST:WELL_, FOUNDATION PIIDPERTY UNE I HERESY CEATFY THAT I HAVE PFEMRED TNI APKJCATION AND THAT TIRE NOIK WILL BE DONE M ACCORDANCE—H SAN JOAQUIN R COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS Of THE BAN JOAOUIN CDLMTV,HOME OWNER OR LFCENBEDAGENT'S Ito NATURE CERTS#B THE FIALOWE•IO:'ICMtSy THAT IN TIEPENORMANCE OF THEWOISL FORIYHK:H-^,Ev THIS PERMIT 16 ISIUED,I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECOME SUBJECT TO tAOq.:MAN'■COMPENSATION LAWS Of CALIf01NA." CONTRACTOR'S HIRING OR n SUBLDNTRACTINO SIGNATURE CERTIFIER THE FOLLOYMM:-1 CV(TIF/THAT IN THE PERFORMANCE OF THE WO►R FOR WHICH THIS PERMR IS ISSUED,I SMALL EMPLDY PERSONS SUBJECT TO 1PFb� WORKMAN'S CDMPENSATW LAWS OF CALFORNIA.' TFE APPLICANTM410111 CAII 24"DUR8 M ADVANCE FCA ALL ISO{MtEn IJTSPEICTOTNI. COMPLETE DRAW1110 oY PER. aONED X �� TRTLEI �vGJ rl/_ DATE: E yZ .5- ROT PLAN MfIAW TO SCALEI SCALE 'IS 1.NAMES OF STREETS OR ROADS NEAREST To OR BOUNDING THE PROPERTY, 4. LOCATION OF H008C SEWAGE DIBPOM SYSTEM OR PROPOSED S. oUTUNE OF THE PROPERTY,METH DSJENSIONS AND NORTH DIFECTN]N. EJfPANS10N OF SEWAGE DISPOSAL SYSTEMS, ]. DIMENSIONED OUTLINES AND LOCATION OF ALL E—NO AND PROPOSED STRUCT%hlW4, {,LOCATION OF WELLS E DISITHIN RADIUS OF ONE MJP1011ED ENT!n ON NCLIIOSSS COYIRD MEAS SUCH AS PATIOS,DHVIWAYS,ANO WALKS. yr THE PROPETRY DR AD IGBFFG PROPERTY_ . ,. .i. ; :. ..I ..... .. .iy fl. .. 30 � � . .:.....:.. a. 4 ' it s .. . : ...:........ Z. IN ....:. . . :. I . . . . .... . ... . . . ..... ..... ... .. i .. 6.....: ....$.._:. .'. Jy. 70 . .( FOR DVARTMRVT US60FIlT � APPPPUCCATION ACCEPTED BY LI� GATE " _ Q APES I�(��N( OR r. CTION IVIF DAT E4 FINALSISPECTION DATE L ADOETK)NAL COMM ACCOJNTINO ONLY: AUDI FAC/ 1 FPtCODE FEE INTO AMOUNT RRMTTED HEC !CASH RECEIVED■Y DATE 8111 PEF"t Nk%um SNOICE S