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APPLICATION FOR LIQUID WASTE PERMIT J '.lOAQUIN COUNTY PUBLIC HEALTH SERVICE$"" ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38%304 EAST WEBER AVENUE,STOCKTONI CA 9001-M (209) 481.5420 9011 WUNDAOLE PENN[[„KjtIf[E3 I MR FGOK DATE l88UEG IGmplass IS Tr40Estr{ APPLICATION IS HENIESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR SMALL THE WOR%DESCRIBED. THIS APPLICATION It MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTYM7 714 - TITLE.CHAPTER 9-1110.3 AND THE STAnDMOs OF SAN JOAOUIN COLMYrY PUBLIC HEALTH VICES.LINA' RDNME AL HEALTH DIVISION. JOB AppIESS10IL APRN# CRY LOT SIZE J OWNER'S NAME ADOMIESS PHONE x" • / CONTRACTOR ADDRESS LJC# PHO NO CONTRACTOR ADDIES6 LICA RHONE TYPE OF SEPm WORK NEW INSTALLATION 0 MPAILMADDITION b"Tmx-TION E3 IND SEPTIC SYSTEM PERMITTED IF PUBLIC NEWER R AVAILABLE YWrHIN 200 FEET OF BUILDING.) PSRC TESThI I 1 HOW MANY Afee/en# INSTALLATION WILL SYNE: RENDENCEX GCOMMERCIAL 13 OTHER 13 NUlAtE1 OF LIVIIO UNITS:_I NUMBER OF BEbNDOEE .. NUMSEEI OF EMPLOY®Sr CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PrrmUMP SOIL CHARACTER: WATER TABLE OEPT11 SEPTIC TAWJ0MEASS TRAP (3TYPEmFO CAPACITY NO.COMPARTMENTS PIES WMATMEIT PLANT❑ OISTANCE TO NEMIET: WELL FOUNDATION PROPERTY LIME I FT STATION 13 SITE TYPE OF PRIMP SAND OIL SEPARATOR IMLOSED SYSTEMA LSACISNS LINE AND.Si LENGTH OF LINES ;2 !- DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RLTEL m O WIDTH LENGTH SEPTI DISTANCE TO NEAREST:WELL FOUNDATION RHDPEMHTY LIME MOUNDED D wom LO4GTHH DEPTH DISTANCETO NEAREST:WELL FOUNDATION PROPERTY LIN[ ifES•NE 1'ITS � �Df PTH SRl NUIABER DISTANCE TO RE AIESrI WELL FOUNDATION WIOPERTY IIID SUM" CI WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATIDN PROPERTY LINE r-- bISPOSAR.PONDS ❑WIDTH LENGTIH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE Q I HEREBY CERTIFY THAT I HAVE FIEPARED THIS APPLICATION AND THAT THE WORK WLL A DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RAM U AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SGMATLRE CERTNES THE FOLI.OHMNS:7 CERTIFYTHHAT SN THE PEM•OMM ANcE OF THE WORK FOIL WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANLIER AS TO BECOME SUBJECT TO VJDWJAM'S COMPENSATION LAWS OF CALL KWAA.' CONTRACTOR'S HANG OR *US4X NTIVICTHNG NGNATUIE CERTWKS THE FOLLOWING:'I CERTIFY THAT IN THE PEFOOM MANCE OF THE WORK FOR WNIILMH THIS PEISMTT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOHELMIAN'S COMTZ CaXj APPLICANT MUST CALL P24 HOURS W ADVANCE FOR ALL ffil EMI®INSPECTIONS. COMPLETE DRAWING SELOW. SIGNED X TTTLE: C� F L��' ° DATE: S� I-U7 PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PIIOPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLOW OF THE PRDPO".WITH DI MENSKM AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. OIMENSIONEO OUTLIVES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. S. LOCATION OF WELLS WITHIN RADIUS OF Ff.ON INCL MOWS COVERED AREAS SUCH AS PATIOS,DR IVIEWAYS,AND WALKS. THE PROPERTY OR A06KHNWM k. .baA. . .. � .:::.:. : . ... . � .. .. .. _ .. .. :. . . : . ...:. .. .............................. ................ M A ...... 99� :6AN QA Lila E, rKa ' iHf .FiAL7:'. ' .....:....... ......... . .. ... . . ....... ....:...... .... .:.... .... :. H .......................... .....: .......................... ..........................:........... >...... 6 FOR DEPARITMENT USE ONLY f APPLICATION ACCEPTED BY DSL ATE• - ~ LQ k2 _ __AREA- TAW, EA-TA ,PIT OR SUMP (� [� DATE ! l FINAL INSPECTION By / DATE E U AOO"lONALCOMMEHHTS• JL_ Yid [' lS �.S Gyr /J•�f!/'f7 ["T(/L_ S _ h'1 . 1ACCOU TUO ONLY: AIO# FAC# "COOS FEE INFO AMOUNT RIEMITTED CHECK# ASH RiiCE1VED SY DATE an I PERMIT NUM1E1 INVOICE# 42,10- 4d ;�oq Lk u 0112 0,A7 g