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— FA APPLICATION FOR LIQUID WASTE PERMIT PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION P•O,BOX 988,304 EAST VVEer=R AVENUE:,STocKmN,CA 95201388 F E 8 2 1 1596 (2091 4803420 SAN JC )UIti COUNTY PUBLIC HEALTH SERVICES NON REFURkA9lETERMIT I)SWRES 1 YEAR FROM SATE ISSUED ENVIRONMENTAL HEALTH DIVISION lCompleT#in TTyIiEStLI AFgICATKON IS HERESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. TWO APPLOCATKON IS MADE IN COMPL LAME WITH SAN JOAOUIN COUNTY;F.VELOPMENT TITLE,CHAPTER 8-1110.3 AND THE RT ANDARDS OF BAN JO ADUIN COUNTY PUBLIC HEALTH BFRICEO,ENVIRONMENTAL HFALTH DIVIBON. JDA DRFBS/OR ART./ f G" �_ Cf1Y ,LOT SIZE ADU OWNER'S NAME_ ADDRESS SALYt1C - %ION'' �. s4F•- CONTRACTOR TT"'' _ ADDAF5l uc! RIO S118 CONTRACTOR APOOflFS6 LICP _PHONE TYPE OF SEPTIC WONT(: NEW INSTALLATION❑ RVAIRIAOdnO DESTRIK:TRON❑ (NO SEPTIC SYSTEM PFRMTIFD IF PUR;JC SEWER 18 AVAILABLE WITHIN]DR FEET OF RURDUIOJ PEIC TGTINI I 1 NOW MANY I ApPllowSgl! iMSTALEJL11oN WILL ERBF: RESIDENCE LI COIL MCIV:At ❑ OTHER❑ MUNSER OF UVINO UMTS: NURASER OF 1BE11RO ON H'. _ _ RIIARER OF EMPLOYEES: e� I CHATIACTER OF SOIL 10 A DEPTH OF O FEET:_G PFTISUM,G-.I I'HARACTER:�KS&W f. _ AT.F 7'.1 :.h 1'l 11 v� c)1 SEPTIC TANKNRFAOE TRAP ❑TYPF,mFG . y ^.eNC:TY N;I.CO M'•AJRMFNTS .J ma TREATMENT PLANT Ll DISTANCE TO N£ARFST: L1,TLL FOUNDATION P%DI rRTY LINE O UFT STATION I❑ SIZE TYPE OF PUMP BAND OI.SEPARATOR IENMOSED SVSTFMI LEACMNM UNE ❑ NO.B LENOTN Of LINER DISTANCE TO NEATEST:WELLFJUNOATON PROPERTY UNE FILTER SED ❑WIDTH LENGTH_ OFPTH DNTTANCE TO NEAREST:WELL MUNDATON PROPERTY Low _'yt MOUNOED ❑WIDTH LENGTH___UFPTH DISTANCE TO NEARFOT:WELL FOUNDATION PROPERTY UNE SEEPAOE PITS ❑DEPTH_S17F_4.NUWfR DISTANCE TO NEAREST:WELL FOUNDATION U PROPERTY HF I SUMP# W107Hf FNGTH�DEI'III�DISTANCE TO NEAREST:WE1L��U+OUNOATION ,v PROPERTY 111E , d EPOSAL POND# ❑NADTH LENGTH f:FF'TH DISTANCE TO NEAREST:WELL_ FOUNDATION PROPERTY LONE 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TNF WawL WILL BE DONE N ACCORDANCE'NRN BAN JOwWN COUNTY OMINANCES AND STATE LAWS.ANIS RULES L1 , ANOREOULATIONSOFTHE SANJOAOUIN COUNTY.HOME OWNERORLICENBED AOF.NT'SSR/NATURE CERTIFIER THE FOLLOV~:'ICEMIFYTHATNTIEE PEAFORMANCEOF THt~W FORWIHCH C� THIS PERMIT IS ISSUED,1 WALL NOT EMMOY ANY PERSON IN OUCH A MANNER AS TO BECOME SUBJECT TO WOPAMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTAACTOR'e HIRING OR SUB-CONT INC SIGNATURE CERTIFIES THE FOI LOWNOO:'I CERTIFY THAT IN THE PE1V'ONMANCE OF THE WOSB(FOR WHICH THIS PERMIT ISI#SUED•I SMALL FMF[DY RROON#SUBJECT TO WOW MAN'S NEATION LA RNI THE\APPLICANT AFUST CALL 74 NOW IN ADVANCE KM ALL REOUIIIW IN#PEC/lON6, COMPLETE DRAWING6ELOW. SIGNED TJ / TRI F: DATE' PLAN AN(DRAW TO SCALEI SCALE ' 1. AMEO OF STREETS OR ROADS NFAPE:ST TO OR BOUNCING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPORFD Y. OUTLINE OF THE PROPERTY,WITH DIMENBIONR AND NOTRH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYS/EMB. ]. MWNFIONED OUTLINES AND LOCATION OF ALL EXIS11N0 AND PROPOSED STRUCTURES. E. LOCATION OF WELLS WITFRN RADIO#OF ONE HUNd1ED FIFTY FT.ON INCLUDING COVERED HEAR SUCH AS PATIOS,RMVEWAYS.AND WALKS. THE PROPERTY OR AO.GNINO PROPERTY. . :..... ..:.... : S ttbwsE �o :. : s.... ...... _ r c t . I: . ,�,..�.. .... FEB. 2119% LIG ryt4i.i'4 SERVICES......_ . _. AL HEALTH FOR DEPARTMENT U IF ONLY APP((CATION ACCFRTFO BY - DATE: W '� AREA: TANK,PIT�P -11m..BY DATE S ' +C RNA[NRYFCTION RY DATE /l/ 3 !/ $4 ADd1K)NAL COMMENTS- A I UNTINO ONLY: kID/ (ACP �PE CODE FEE INFO AMOUNT REAMTTEO CHECK AMI RFC DYED BV GATE ER I POWIT NUMBIM NYdCE I �2 �r f�S 1 o. oa m 3 aI 111 IL BS��