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APPLICATION FOR LIOUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 988,304 EAST WEBER AVENUE,STOOMN,CA 95201388 - (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IClmpl$bF In TF4Deehl APPLICATION IS HERESY MADE TO THE BAN JOAODIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APFMA710H 16 MADE M COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS Of BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADORES&OR A/Rl`F^' a'3�-� �. H U U 1 "0 CITY (�.�C Ct I o n LOT SIZE OWMERTBNAME //C�d [1S^C'1 L 11� P ADDRESS ''7 ��/\ (��^ (^.�(p� ( p { PHONE CONTRACTOR_ITAA 2( k 1`Ue ADDRESS -).3L0 - `�-G6 i Jl el l LIC. I Va PHONE Sag-9d5/ BUB CONTRACTOR ADDRESS LIC/ PIIONE-K- TYPE OF SEPTIC WORK: NEW INSTALLAMN❑ RIVAIRRA0b1TloN DEITRUCTION❑ IND SEPTIC SYSTEM PERMITTED F PUBLIC BEWER IS AVAILAftE WITHIN 200 FEET OF BUILDING.I PSIRC TESTR.I 1 1 NOW MANY y Ap"load-INSTALLATION WILL SERVE: RESIDENCE.maqS COMMERCIAL❑ OTHER❑ N4MIE1 OF)MNG UIGTS: 1 NUMBER OF SmROOMS: MWSER OF BNPLOYES'DL: CHARACTER OF BOIL TO A DEPTH OF 3 FEET: PITIODUP BOIL CHARACTER: WATER TABLE DEPTH SFPTIC TANKJORFASE TKAP ❑TYPE.MFG CAPACITY NO,COMPARTMENTS PKG TIRAT?MNT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LFT STATION❑ SITE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UWE 0 NO.•LENGTH OF LINES Lf o 1 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SmAGE IRS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SWM WIDTH LENGTH 40' DEPTH DISTANCE TO NEAREST:WELL ICO' FOUNDATION PROPERTY LINE OIMOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WALL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCE$AND STATE LAWS,AND RULES AND MOULATIOHS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'6 SIGNATURE CERRTIFEW B THE FOLLOWING:'1 CERTIFYTNAT IN TME PEI FORMANCE OF TIE WORK FORYMIICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERSST IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WOFKMAWS COMPENSATION U OF CALIFORMAI' T/IE AMT MUST CALL 24 HOW IN ADVANCE FOR ALL 14FMMEO INSP.TTONS, COMPLETE DRAINING BELOW. SIGNED TITLE: C)io IQr- DATE: /o-19- /9 PLOT RAN(DRAW TO SCALER SCALE-'I. 1.NAME$OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. FXPANMON OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OLITUMES AND LOCATION OF ALL E%WTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WTMN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOP"NG PROPEREY. .,. .. . ..:....:.......... i.... .... ys� � z .. P, v►uc�t�c _ . .. _ 1� ,� his � . ..'..,. ..i. ht;JUAPQJN (Yl1N.TY- EFYlC£5 ' FH DNI910N; usdc FOR ROEPMTMdT USE ONLY APPLICATION ACCEPTED BY v' ! DATE: AREA:—2 {I �j TANK,PIT OR SUM INSPECTION SY DATE/Q!4FINAL INSPECTION DATE�CJ h�S ✓l ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDS FACT PE CODEFEE INFO AMOVNT 11E.ITTEO CHEC !CASH RMEWED BY DATE SA I PERMIT NWBSR NNOICE o�O