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APPLICATION FOR LIQUID WASTE PERMIT SAN•JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION L .0.BO7f 388,445 N.SAN JOAOUIN ST.,STOCKTON CA 96201.0388 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FRDN DATE ISSUED Momplow in TTQIieaTal APRKATION IS HEREBY MADE TO THE SAN JOAOWN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED,THIS APPLICATION 16 MADE IN COMPLIANCE WITH uN JOAOUIN COUNTY OEVELOPMENT TITLE,CHAPTER 5-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PL16LIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISIOIi, JOB ADDRESSL3-7--3 OR APN., Jy�yye/ �_�1��t �h•� r CITY` 7 r m� LOT SGE OWNER'S NAME ��1 � ' 3 1J�{ 1 _ADDRESS �f4m r-J �•- 'JI��^�QRICNE CONTRACTOR kl fa ADDRESS3?X`6--�') Sn 1 KAI T�lnu.- SUS CONTRACTOR ADDRESS UCt PRONE TYPE Of SEPTIC WORK: RIEW IN&TALLATIOw EP REI•AIIVAODITION ❑ D"TRUCTION❑ INO SEPTICSYSTEM PERMPTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF WLDMIG,) POIC TFETMI I I NOW MANY �� App&uPSon t NATALLATION MALL 4SRVE: G. - AFBIDENCE 60UMERCIAL❑ OTHER❑ NUMBS R OF LTVINO LINTS: / NIMOF NLMCB[Df gJPLOYRa: r 7� CHARACTER OF SOIL TO A DEPTH OF 3 FEETBI PIT?SUNP SOIL CHARACTER: WATER TABLE DEPTH_ $BINK TAMKIGIREASE TRAP ❑TYPEIMFO .r CAPACITY_l NO.CO/APA/17MDR8 PKO TREAIAENi PLANT❑ DISTANCE TO NEMFJi: WELL FOUNDATION ac, PROPERTY UNE FFT STATION❑ SSE TYPE OF PUMPS SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING UNE 0-co.p LENOTH OF UNEB_a-; (J- OISTAMCE TO NEAREST:WELL JA D FOUNDATION yia PROFERN UNE yJ FALTER Gm ❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LAW MOUNDED ❑WROTH LENGTH--DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE &WAGE PIT$ ❑DEPTH SSE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LM (f 1 SUMPS D WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE / DISPOSAL PONDS ❑WIDTH LENGTH DFPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON,WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAM,AND MRES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR UCENSEO AGENT'S SIGNATURE CERTIFIES THE TOLLOWWO:•I CERTIFYTHAT IN THE PERFORMANCE OP THE WORK FOR V."CH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WONDJAN'6 COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR 77:;A�N'S GSIGNATURE CEFTTFESTWE OLLOVNNOTTY THAT IN THE PERFORMANCE QF TWE WOF7T.FOO WHICH 7HI8 PEWAR IS ISSUED,I BHA1L FAP,OY PERWNS 8U&IEC7 TO PF"ON LAWS OF F OU..'_INE APPLIfOR ALL 0 WHIREDIN$►fCTONi-CO ED,I S dUWNf BELOW.� b� �.r�rsY � `--� TrrLr.:Lb'24�'�,rS�IP�� oATE:,1Li / ? IJ\ PLOT RAN[DRAW TO SCALEI SCALE--'to 7. NAMES OF STREETS OR ROAOS NEAREST TO OR BOUNDING THE PROPERTY. 4-LOCATIONOF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PIIOPEITTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS- 3. WIENSI DIMENSIONED OUTLINES AND LOCATION OF ALL OUSTING AND PRDPOSED STRUCTURES. 6.LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED,HFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DWVE}VAV$,AND WALKS. TIE PNDPERTY OR ADJOINSA PROPERTY 4 • : ....... . ... . a• • . .... ... . .. . :.. .... . . .... .. . ......... . .. ................... . S .... . ...... ... - ...... . . . . :.. .:M-- : � '7 — .I 1:;�ZFOAtPARTN9IT UAE ONLY Q APPLICATION ACCEPTED BY c DATE:_ L � APF/c. z r Q /TApK.PIT OR SUMP INSF•EC710N SY DATE1/r,�C/FINAL LNgpECT1pN "7" pATE �I!�1 y ADDITIONAL COMMENTS; T ACCOLMTNO ONLY: AUDI FAGJ PIE of FEE INFO AMOLINT RDAITTM CHEOKt/C H RECEIVED BY DATE am U PERMIT NL$.Ral INVOICE• .1