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APPLICATION FOR LIOUIO WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388,904 EAST WEBER AVENUE,STOC MM,CA 95201588 (209)463-3420 NOM-IEFUNDABLE PERMIT EXPIRES I Y AR FROM ISSUED 11:SSIPIStS in TFlpikitfl APPLICATION I8 PERM MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCNBED. THIS APPLICATION IB MADE N IT COMPUANCE WITH BAN JOAQUIN COUNTY:IEVELOPMEM TrTLE•CHAPTER 1-1110.3 AND THE 91ANDAMS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIIAWJN. JOB ADDRESS/ORM APN.E_ `9"I 1Q� --��.P�,(i��-L,�y/- /tI�/ CRY j�L 1FO 1 1 y LOT 81ZE _ OWNER'S NAME L L Gt3 d't-.cSe- ADDRESS_ S'C�Et C_ �oF.ES 46 CONTRACTOR ADDRESS J / -L ICO ^ CI PHONE TL SUBCONACTOR I �� rf.LII 'r ADORES6en -_6J V UCiC20YG-'5-E4 PHONE 3q=r7 73 TYPE OF SEPTIC WORK: A1EW INSTALLATION❑ REIWRIADOITION Zr DNTRUCTION❑ WO SEPTIC SYSTEM PERMITTED S PUBLIC SEWER IB AVAILABLE WTTHIN 200 FEET OF BUILNNG.1 I VAC T.TNI I I MOW MANY APWPRBwI I INSTALLATION WILL BVKVN: RESIDENCE 0-COMMERCIAL❑ OTHER❑ IEIIMSER OF WINO UNITA: k NUHSSR OP BEDROOMS: NUMNIM OF IMPLOVEBS: CHARACTER OF BOR TO A DEPTH OF S FEET:SZ1 n t N FTTISULW SOIL CHARACTER: SCApk j WATER TABLE DEPTH (� SEPTIC TANKfOREJUE TMP C;r--F(I ef-( ,JACUf Li-Q^CMACITV__`4 DL�-_f NO.COWlARTWNT9 Q T _ -� PKO TREATMENT PLANT❑ DISTANCE TO NEAMT: WELL 9 j11 FOUNDATION 3 7 RO iP',RTY UNE ')n! LIFT STATION Cl SIZE TYPE Of PIMP SAND OIL SEPARATOR IENCLOSED RYSTEMI t I CfI �_ —_lL l0 -� IEACNMo LHII f�y NO.h LENGTH OF LWES�.-,�j� DISTANCE TO NEAl1EQT:WELL_!FOUNDATION "1 PIIOPENTY UNE ryryU FILTER TED y WIDTH LENGTH`_DEPTH DISTANCE TO NEAREST;WELL FOMAIDATKNY PROPERTY I" MOUNDED ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELL _FOUWATtON PROPERTY LINE IMAGE PIT$ �0 DEPTH 812E NUMBER 019TANCE TO NEAREST:WELL_ POUNOATK)N PROPERTY U SUMN /yF'TT 1NDTH i LENGTH `n' DEPTH^I f�1 NOT ANCE TO NEAREST:WELL a'FOUMATION�_PROPER"LAZE t p L DISPOSAL PONDS I WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_ FOUNDATKIN PROPERTY LINE - I HEREBY CERTIFY THAT I HAVE PREPARED TH19 APPLICATION ANO THAT THF WON[WILL BE DONE M ACCOROANCE WITH SAN JOAQUIN COUNTY ORDINANCE8 AND STATE LAWS,AND NUI-ES AND REOULATTONS OF THE BAN JOAOUIN COUNTY,MME OWNER OR UCENSEV AGENT'S SIGNATURE CERTNIES THE FOLLOWNIO:1 CFM IFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNEN A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOF"A.' CONTRACTOR'S I/INNO OR 7V SVBLONTMCTING WONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN:HE PERFORMANCE OF THE WORA FOR WHICH THIS PERMIT IS ISSUED,I WIAL1 EMPLOY PERSONS SUBJECT TO WOWMAN'B COMPENSATION LAWS OF CALIFOPMA.- THE APPLICANT MUST CAL•.24 HOURS IN AOVANCf FOIA //ALLL REQUIRED INSFgTONS. COMPLETE DRAWING BELOW. C SRTNED% L� TITLE L`V UL�f SGS T DATE: O ,�J PLOT PLAN IORAW TO SCAUEI SCA,E 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOU140M THE PROPERTY. laRO 4- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OtRHNE OF THE PROPETTTY,FIRTH DIMENSIOND AND NORTH DIRECTION. EXPANSION OF SEWA3E OtSPOSAL SYSTEMS. 9.OMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURFS, S.LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREA$SUCH AS PAT VEWAYS,AND WAUIL8. THE PROPERTY OR AOJONNG PROPERTY, YIO e- 14 1 S?cs-0- klo 1 I .. OCT 2.1 1995 f-c n hEcr�,.stRwc .. . Ghl C M,jA IQ� �arRont{ rp N4, NDrlfiSft]h: FOR DEPARTMENT USE 0 APPLICATION ACCEPTFU BY L/y�IN1�l�+�MT DATE: I. S AIVA:� -J TAN(,PIT OR SUMP INSPECTION BY 0ATIE I // FINAL INSPECTION BY DATE_L�l( 2 71 !�I ADDITIONAL COI,NAEMT6- (f,�LQ ACCOIAETNO ONLY: AIDI FAC/ y/ PE COOS FEE INFO µMOUNT REMITTED MASH EIEOBVEs 1T DATE M(P[RMPT NI/,1101 MNVOIC[I '1 -75 4-2- ~ ^ - ; SRoao��59 ,