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Y.� APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468.3420 NON-REFUNDABLE PEANRT EXPIRES l YE1B FROM DATEISSUN ICSISvwtB 1•Tr4ia1E) APPICATION NO HERESY MADE 70 THE SAN JOAOVIN COUNTY FOR A FEiMR TO CONOTRVCT ANG/Oft MBTALL TNF WOIK DESCRIBED.THIS APPLICATION IS MADE IN COWIIANCS WITH SAN JDAOLRN COUNTY DEVELOFWENT TITLE.CHAPTER 9-1110..3 AND TND THE STANDARDS OF SAN joAWN COUNTY PUBIC HEALTH SERIACES,ENVIRONAIDFTAL HEALTH OMMON. JOS ADDRESSAHU— �J a/ � Izlz a,,p WYHER'S NAME /��.5 /,}�% ADDRESS CJ^�J SIS •A/��S/ iG L>-JO i 7> /1�� PHONE_ CONTRACTOR• /, /�L-L CYCC ADDRESS �11� / /Il�uc, WR CONTRACTOR ADDRESS gyp/ UCN !NONE TYPE OF SEPTIC WORK: NEN TNSTALLATIOII Q REDAMADOTTION DIF OEYTRUCTION❑ INO SEPTIC SYSTEM PERRTTEO F YVBLIC SEWER IS AVMA.-BLE WITHIN 200 FEET OF SKNlDMO.F P9tC TLTNI I I WVLFF MANT AN INSTALLATION INSTALLATION WILL SONE REBIOENCS)d COLIMERCIAL❑ OTHER[I /U NVIAM V L14M0 UNITS: MUN"m O//i�I/A�NDROOMS:�NIRASER G PIAPLDYMS: CHARACTER OF SO&TO A DEM14 OF 9 FEFT:-A4T 017;l� PTT/SUMP SOIL CHARACTER, WATER TANI DEPTH 6EPM TANKAREASE TRAP ❑TYPUM4 CAPACfrY NO.COMPARTMENTS ^1J WO TREATMOIT PLANT❑ OISTANCS TO VOAEOT: WELL FOUNDATION PROPERrY UNE 2.7 jAyT10R Cl 812E TYPE OF Ft1MID P SAOILBEPAFUITCR(E11GlDbEO SYSTEM IlA.GMNO IW/CC�R E3 NO.N LDDTN OFLINER I`��JC-J f r DUTANCE TO NEAREST:WE111�FOVNDATgN PROPERTY UNE FILTER SED ❑WIDTH LITIOTN OFYTN DISTANCE TO NEAREST:WFu FOUDATION PROPERTY UNE ' n"F7 NI0UkCED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL_FOUNDATION PROPERTY UNE e� SMA01 NTS D DEPTH SEE NUMEIRDWrAN CE TO NEAREST:WELLtOUNGATION PROPETDY UHE SWAM 0 IYToTH LENGTH DEPTH DISTANCE TO NEAREST:WEL •_POUNDAn10N F OPERTY UNE DISPOSAL PONOS ❑MDT" UENOTN -DEFTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HERESY CERTIFY THAT 1 HAVE PREPAPEO TWO APPLICATION AND TWAT THE WORK WILL BE DONE IN ACCORDANCE WITH lIA N JOAOUIN COUNTY OFIOSLLNf18 AND STATE LAWS,AND RULES �J AND REGULATION OF THE SAN JOADIISI COUNTY.HOME OWNER OR LCEN SM AGENT,S OIONIATLRRE CERTWKSTHOFOLLDKWWO:9 C ORTFY THAT M THE PEIPOM AMC E OF THE WDK FORWRBCN C/ TIRO P"MET tt ISSUED,1 SHALL NOT OUPLAY ANY PERSON M SUCH A WAVIER AS TO SECOSAE SUSJICT TO W omLI AN'S COMPENSATION LAWS OF CALMO MA-'CONTRACTORS MRMG OR SUSCONTMCTMO SIGNATURE CERRRES THE FOLLOWING:'1 CERf1FY TNAT M THE PEF"FNIANCE OF THE WO1K►VR WHICH T'NS PENAIT IS ISSUED,I SHALL EMPLOY PERSONS SUWECT TO WORKMAN'S CONAFENSATION LAWS OF CALIFORNIA." THE APPUCART MUST CALL b HOURS RR ADVANCE FOIE AU.NaL.tMSP6.THgIS.COMPLETE ORAWIFIG OELOW. SIGNED X /.C� -' TITLE; �A`- DATE: / ROT RAN IORAW TO SCALER KALE 'ro T.NAMES ND OF STREM OR ROADS NEATEST TO OR BOUNDING THE PROPERTY. A•LOCATION OF HOUSE SEWAGE Dt3 GOAL SYSTEM"PROPOSED 2.OIfTLOE OF THE PROPERTY.WITH OSAQ ONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. OUTLINES 3. ONAENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTlM1EQ S.LOCATION Of WELLS WITHIN RADIUS OF OM NLR D FIFTY FT.ON INCLUDBIO COVERED AREAS SUCH AS PATIOS,ONVEWAYS,AND WALLS. THE PROPETTY OR ADJONNG RRDPDTTY- �7 ........................... Z. _..� • :... ..... ..: ..: :. ...:.......:.... ...........w.<..... .A .:.....;. . '...i.... .......... ' :.. AD I .... ...........i ..L...........i.....ty':t1'�yj`d.�. !.:�. ... ... ...'^_._..� :....... .......... _ .... ....._ ._.....:............. ............................. . x ..:.. ...... . ;.aAhJCyrKQlgN•6E•AL3NfY.. ..<....L... .. . : ;PUBLIC FIEALTH oEFNI i ......... -.._.. •yR..:. - . ...... ... . ..... ....:... .. ..wiRaNUF'��ri'KE;a'!axi'�Iv!sia�" APPLICATION ACCEPTED BY SOATtTSSONT OSS ONLY GATE: A: /CJ 2 ) TAM.PIT OR DUMP RIBP 10 BY DATE 1 / _ FMK INSPECTION OY DATE ADDITIONAL 0OWAAENTsSY ACC01MTMi0 ONLY: Aro. FAC. PO CODE FF£INFO I AAAOKaRRMITTO ASH REEVED IT DATE /PF/NST IRSNSEI Ift-ro u2io li r o Pub.Heahh Serv.-Enwo.174(3M)