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APPLICATION FOR LIQUID WASTE PERMIT 17 SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O.SOX 388,304 EAST WEBER AVENUE,STOCKTON,CA SSMI 388 (2098 468.3420 v 6 Z NON-REFUNDABLE PERMIT EXPIRES T YEAR FROM PATE ISSUED � /, i7� (tamp)&"IF TripNraW L/ APPUCATION IS 4ERESY MADE TO THE 15.JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIM INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMRL!ANCE WITH SAN JOAQUIN COUNTY DEVELOPM (/rr[.E•CHAPTER 9-1110,3 AND(7HE�STAAN�D(/MOS^O�F1..JOAWN COUNTY PURUC HEALTH 8ERV1C78, PDNMENTAL HEALTH OMAWA4. JOB ADDREGS/O/R/A�'Fq'Ne { (W LOT oWTIER'R NAME--T/�I-�\y ADDRE88 '//� PHCrx CONTRACTOR '_—T�� ADDRESS LILY FHDw 6U8 CONTRACTOR U ADDREBS'�/� Sfyl 4!, L.IIGr-C- LACE T2ZSr PHONE'LT TYPE M SEPTIC WORK: NEW INSTALLATION RMANVAODITION ❑ OUTRLCTION❑ IND SEPTIC SYSTEM PERMITTED IF PWUC SEWEA HI AVAILABLE WITHIN 200FEET OF BUILDRKN.I POD TEFT[.1(I NOMI MANY Awa—d—I INSTALLATION WILL SUM: RESIDENCEER [3COMMCIAL❑ OTHER NU MBIP OF tIVRNO UNITS: / NUMSHi Oi s OOMA' 3 NUMBER OF BAP 0—: C CH ER OF BOF.TO A DEPTH OF 9 F1EET,C y PITMUMP SOIL CHARACTER: WATER TARE DERM r/d C T I K)OREASF TRAP ❑TYPEEIIMFMFFO'Mnt :T-4 L— CAPACITY NO.COAWARTMENTS PILO TREATMENT PLANT 0 DISTANCE TO NEAAEJT: zznn'L FOUNDATION�r� PNOP2RTY UNE d�Gd �l LIFT STATION❑ SIZE TYPE Of PUMP /SAND OIL SEPARATOR IENCLOSED SYSTEMI_ LEACHING UNE NIR.A LEWTH OF LINES �lO� yyLr-I'� DISTANCE TO NEAKBT-WELL�FU NDATIONU _/PROPERTY LwE loci l,( RLT91 FED Q WIDTH LENGTH_!OEPTIN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL _FOUNDATION PROPERTY UNE SETPAOC FRS ❑DEPTH SME NUMBER DISTANCE TO NEAREST:WEU.__FOUNDATION PROPERTY IPE BUM" ❑WOTH LENGTH OEPT/I DISTANCE TO NEAREST:WEU. FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL__FOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUNN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REOULATIONS OF THE SAN JOAOVIN COUNTY.HOMEOWNERORLICE l�AOENT'G SIGNATURE CERTIFIES THE FOLLDWING:•I CERTIFYTHAT W THE PERFORMANCE OF THE VJOPS(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A R AS TO BECOME SUBJECT TO MMMAW8 COMPENSATION LAWS OF CAUFORNIA.' CON7RACTOR'F MRRJO OR SU"ONTAACTING SIGNATURE CERTIFIE THE FOLLOWM:'I CERTIFY HAT THE PEREDRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT 70 WOPXMA C NSATION WS OF gN1A,• THE APPLKAN MUST k HOURS IM ADVANCE ioq ALL REDU11p RgF[CTONa. COMPETE ORAW/Ri0 BELOW. 9 SIG X 7TTLf: bA7F;___�f OI JY PLOT RAN(DRAW TO SCALEI SCALE e I,NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. T<. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED \.. 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DDPOSAL SYSTEMS. \.1 9. DIMENSIONED OUTLINER AND LOCATION OF ALL EXWYMM AND WDP'OMO STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE NUNORED FIFTY FT.ON INCLUDING COVERED MEAS SUCH A8 PATIOS,ONVEWAVS,AND WALKS. THE PROPERTY OR ADJOI/NNO PROPERTY, , , ;. ...... . .... J.1; ...... :.. .<... .... .:.... :. .......... :.... . . . _. .i. .. <.... .. i. j(o .. .. ... .. .. . . . .. fes. i P JUIL-ii C. 5 . . J dlN .. .... .. .'. ITFW........ ..... i... .:..Et�1RRGIyNP,'TkjfjEkETI b;�lUi3�lh ....fid ................ .. 1 DWARTMMT USE ONLY APPLICATION ACCEPTED BY DATE: ' �f/1 AREk TANK,PIT OR SUMFl NSMCTION 11 OATE7 7T4' FINAL INSPECT,HBV DATE y!/31" ADOMONAL COMMENTS: ACCOUNTING ONLY: AIM FACN PE CODE FEL INFO AMOUNT REMITTED C E/CASH RECEIVED By DATE M 1 NII.B91 INVOKE/ r J 3 t.6 I -1 ,n/o�