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APPLICATION FOR LIOUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOR•11Ei0N0A81E PERMIT EXPIRES 1 YEAH FROM DATE ISSUED ICo"Ie!In Ti(PYatt) APPLICATION IS HEREBY MADE TO THE RAN JOAOUIN COUNTY FOR A PEJRMIT TO CONSTRUCT ANDAINSTALL STALL THE WORK DESCRIBED, THIS APPLICATION 16 MADE IN COMPIfANCE WITH SAN JOAOUIN COUNTY DEVEL.OFMENT ,CHAPTER 9-1110.7 THE BT ARDS OF! AGURN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIMM AA--P•NI C/ ` -Cly--61-1i— LOT SIZE► OWNER'S NAME V ADDRE R PHONE /O CONTRACTOR ADDRESS PHONELice SUS CONTRACTOR /// /-�'� �w�'/� y� AOOL�SE� `-+ r/ _ C- Lice V�•'� ALO /�/ TYPE OF S"MC WORK: NSW INSTALLATION ❑ PXPAIR/AOOBTIO DESTRUCTION❑ IMO SEPTIC SYSTEM PERMr TEO If PUBLIC SEINER IS AVAILABLE WRHIN 200 FEET OF N0.1 PITRC TESTIBI I 1 HOW MANY �� A&gSe�llew f M � INSTALLATION WILL tf3tVE RESIDENCE❑ COMMERCIAL ❑ OTHER hANABER OF UMMG UMTS: NUMBER OF S ROOMS: N ER OF BMfLOYEES:_ t1V / Of 800.TO A DEPTH Of FELT: PR/SUMP SOIL CHARACTEFOKWATER TABLE DEPT ❑ N0.COMPARTMENTS CAPACtTV � 0 OEAA2TINZAT:ERT RANT❑ DISTANCE TO NEAREST: WELL FOUNOATK)N Iv PROPERTY UNE 101C) , C LIFT STATION❑ SIZE TYPE Of P11MP SAND OIL SEPARATOR tENCLOSEO SYFIEMI �\ LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREET:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WEL1 FOUNDATION P14OPERTY UNET_ SEEPAGE ATS EPTHRIZEIy _NUMILER ✓ DIST A/dCE TO HEAAE BT:WELL '�fOUNDATION�R10PERTY UNFy�_^ BUMS C ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PO#WS ❑WIDTH LPNOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE VAT"SAN JOAOUtH COUNTY ORDINANCES AND STATE LAWS,ANO RULES AND REGVLATIOMB OF TIE JoAOl1wL C0 .NO ME OWNER OR LIC ENSEO AGENT IB SIGNATURE CERTIFIES THE FOLLOWI10:ICEITTIFY THAT IN THE PERFORMANCE OF THE WORK FORWHK Too IT ISSUED, NOT E11ZIU PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT TO WOIKMAKS COMPENSATION LAW!OF CALIFORNIA. CONTRACTOR'S MItlNO OR J/ ONT T A CERTIFR6 TH LL 'T CERTIFY THAT IN THE P[1EORiMAHCE OF THE WORK FOR WHICH THIS PEMAi le 1lSLJED.I SMALL EMPLOY PERSONS SUBJECT TO AS M OFC T U!T CALL 24 NOLUR!IN ADVANCE FOR ALL REQURm P"FECTIONS. COMPLETE DRAWING BELOW. /J ��y/�J'L� DATE: , X /N TITLE: L PLOT PUN M#IAW TO SCALEI*CALF_ 1, NAMES O STREETS ROADS MEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED / 2. OUTLINE OF THE PROPE ,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYYTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED BTRUCTVRES. S. LOCATION OF WELLS WRMN RADIUS OF ONE HUNDRED FIFTY FT.ON IICIUDINO COVERED AREAS SUCH AS PATIOS,D MVEWAYB,AND WALKS. THE PROPERTY OR ADJOIHINO PTIOPERTY. S. .... ,. / ..........�.. ........,. ...............i.. :............ _.. .... .. �_ . . ..... G >........ . moo as et . .:... :.... .. ........ . ............�. . . .. ...... .. ... ; ... ......,-.... ...... ....., .. .. 3 .. . , V J .. \ �v ..... y........... • 4. .� .. .. .... ...... .. .. .. .... .. ....... .. ......�.... .. S -• - - ... .. .... .. ........ ......... C .......... ............. ....... ............. ... ; ........ --, FOR DEPARTMENT USE ONLY ARTUCAiION ACCEPTED BY — .._� _ GATE: "• .� •,�`,••. ....•••""""" AREAI •gyp G (1ANIc{yll Vn SUMP WSMCTION BY v� DATE 1?71 FINAL INSPECTION BY � DATE= Iy D 1 4 ADDITIONAL COMMENTS- I ACCOUNTING OWY: AID/ FAC& R CODE FEE INFO AMOUNT A[Ml I ICA&H RE'CEVEO BY DATE 1 SR 117MRT NUMSM INVOICE& O ©�I Pub.Health Serv.-ErMto.174(3196)