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APPLICATION FOR LIQUID WASTE PERMIT <br /> S SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,446 N.SAN JOAOUIN ST.,STOCKTON,CA%201-0388 <br /> (209)468.3420 <br /> NON•REFUNOABL PEI/R/M,,,�I,T,,E%PIPES 1 YFAp FpON DATE ISSUED <br /> APPUCATfJN IS HEREBY MADE TO rw SAN JOAQUIN COUNTY FORA CONSTRUCT N TTi 8INST <br /> �• JOAOUIN COUNTY E STAN Tp CONSTRUCT OAQU)N INSTALL THE WORK DESCRIED.THIS APPLICATION L MADE IN COMPLIANCE WITH SAN <br /> DEVEIOPMEM TITh,CHAPTER 9.,7 70,3 AND THE STANDARDS Of SAN JOAOUIN COUNTY PU6Ut HEALER SERVICES,fNVtAONMENTAt HEALTH pVISK.N, <br /> JOB ADGRESSORANp 2.5->'`Jo r9aJ>tc� Raj' <br /> /1 � <br /> Cllrsit•" <br /> OWNEF'6 NAME L• g _LOT SDE <br /> ADORF hrELr "1 371 <br /> suecoNTRacro <br /> ' .^.ONTNACTpR�/�fLG�Y 'B 5 Cf A/ ADDRESSu dLZ'•�. L p <br /> _ S' PHONE '��7'ffG9 UC7 y���� PHONE 1..�'SSR•!'S <br /> q A � <br /> DDRESS <br /> LIOE PHONE <br /> TYPE OF SEPTIC W0RX; <br /> NEW INBTILLLA'19ON L7 RPFAAVAOd TION - <br /> (No SEPTIC SYSTEM PERMITTED If Y DflTR:IIC7ION❑ <br /> PU3GC SEWER!b AVANAB[E W17lRN 200 FEEL Of BWLiNNG,) <br /> P@tC 7fdT!•I!I NOW MANY <br /> INSYAILATION WIU-SERVE: RESIDENCE a1 CGMMERciu DAppNc•tlpP A <br /> OTHER[] <br /> NUMBER OF UVNIO UMTS; I NUMBER OF �-'— <br /> lEDROOMl: ,; <br /> CHARACTER Of SORE TO A DEPTH OF <br /> ]HET; NLE am OF EMPLOYEES: <br /> <� <br /> SS"C TAWUOREA&V TRAP -� PtT�SUEAP SOIL CHARAC7FR; <br /> CTYFENMFG `��_WATER TABLE DEPTH <br /> (� <br /> DISTANCE 7O NEAREST WELL PNO TREATMSVT PLANT❑ .�_CAPACTTI' NO.COYPAR]"MEN78 <br /> LIFT STATION❑ SiCEPROPE".iTY UNE <br /> TYPE OF PUMP POUNDAnON SAND Ott SEPARATOR(ENCLOSED SYSTEM, <br /> LEACHING UNE {� LENGTH OF LINFS�� <br /> LRS7ANCF TON A <br /> FI7EA Bi7T ❑WIDTH LENGiH E REST:WELL ,YO"'t fOUNOA7roN 3r' PRDi'ERT'T UNE �E" <br /> MOUNDED ❑1VIOTH` '---�OEPI'N DISTANCE TO NEAREST:WELL ATION <br /> LENGTH fl)UNO PROPERTY IlIff`— <br /> AaPAGE PETS DEPTH dSTANCE 70 NEAREST WELL 1 <br /> Q fffP'TH SI FOUNOATTON PRppELgTy LME <br /> NUMBER DISTANCE TO NEAREST:W%L �I <br /> iUMPi ❑H507NLENGTH FOUNDATION PROPERTYUNE <br /> DVlFOlAL pONOB DEPTH IXSTANCE TO NEAREST:WELL FOUNDATION <br /> O WrOTN LENGTH_ DEPTH PROPERTY LBIE r <br /> DISTANCE TO NEAREST-WELL FOVNOATRON PROPERTYGNf <br /> I HERfeY CERTIFY TryAT 1 HAVE PREPARED THIS AI I I ,TION AND THAT THE WORK WN L BE DONE IN ACCORDANCEWlTM SAN JO <br /> AND REGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AOUIN COUNTY ORDINANCES <br /> THIS PERMIT IS ISSUED,I SHALL NOT EM AGENT'S SIGNATURE CENTIMES tHE F0110WINfi:"I CERTIFY THAT IN THE PERFORMANCE AND STATE LAWS,AND RULES -J <br /> SUS-CONTAA,CTING SIGNATURE CERTIFIES THE F'0Y SON iN SUCH A MANNER AS TO BECOME SVSJECT TO NIpIQ(/MAN'S NC"!COMCERTIFY <br /> ANCE OF THE WONL FORWHICH J <br /> • WOPELMAN•S COMPENSATION LAWS OF CAUFO,WIA,• I CERTIFY THAT M-;HE PERFORMANCE OF THE WONT FOR WHICH TMS FEW,LAWS OF,I wOPNIA.'CONTgAcrows HIRm GR C <br /> ! APPLICANT MUST CALL 84 NG—IN ADVANCE FOR ALL NE 18 ISSllEO,7 SHALL EMPLOY PERSONS SUWECT TO <br /> GULPED INSPECTKLNi. COMPLETE DRAWING BELOW. <br /> .. SIGNEL•I( CJI" <br /> • l r ,I <br /> TILE: DATE: <br /> • ,.NAMES OF ST POT PUN(DRAW TO SCALE,SOME <br /> BEETS OR ROADS NEAREST T "LO �J <br /> •` 2.OUTLINE OF O OR BOUNDING THE PAOPEN7'Y. <br /> THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM GA PROPOSED (� <br /> • J.OIMENSKINFO OUTLINES AHO LOCATION OF ALL FAISTINO AND PROPOSED STRUCTURES, EXPANSION OF SEWAGE deP6 <br /> + INCLUDING COVERED AREAS SUCH AS PATIOS, S.LOCATION OF B'•'L BYBTEYB. <br /> DRIVEWAYS,AND WAIXS. WELLS MIITIilV RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> PPK)PER7Y OR ADJDIJVM PROpE1TTY. <br /> y r^c L <br /> ( <br /> i 5'o T <br /> ! / <br /> all <br /> 16 IV <br /> i y{tiP 4e <br /> it-f <br /> Y <br /> MAY 1 2 199j <br /> ;Ar.. <br /> 'ni.�liiN <br /> c '3L,C HFAL 1,3ElR%'IG3 <br /> w 1 � ' "A DEPARTMENT use ONLY <br /> APPLICATION ACCEPTED Ire ' � _ <br /> •* DATE 7 -U / l7 <br /> • TANK,RT OR SUMP IWpECT10N BY AREA: L...�� <br /> DATE_ / 1 FINAL INSPECTION Bl' ? <br /> ADDITIONAL COMMENTS; DATE J ! <br /> O <br /> ACCOUNTING ONLY: AIOI .� <br /> FAC, <br /> • P CODE FEE INFO OUNT REMITTED <br /> C /GASH AECENED BY I DATE <br /> on!PtdBWT NL►OEII INVOICE 0 <br />