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r 11, APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O,BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)465-3420 RON•REFUHDASLE PERMIT EXP RES 1 YEAR FROM LATE ISSUED IC6NplSt.in TrIPRSl16) APPLICATION M HERESY MADE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTFWT ANDNOR N6TALL TIE WORK DESCRIBED.THIS APPLICATION 16 MAGE N COMPUANCE WITH SAN JOAOUN COUNTY DEVFLOPMEW TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUN COUNTY PUNAC HEALTH SERVICES,ENVW40NMENTAL HEALTH OMOWA. 6440P JOB ADORESeroR ATNF y.,, CITY /e LOT AIZEy, ,/ OWNER'S NAME (/.A.V p�/"- J. ADORES! CONTRACTOR ADDRESS UCP6hS� SIM CONTRACTOR ADDRESS UC PHORE TYPE OF SEPTIC WORK: VFW INSTALLATION❑ IE►ARVADOITION OUTRYCTIOM❑ SIO SEPTIC SYSTEM PERIAMFED K PUBUC SEWER IS AVAILABLE WAHW 20OFEET Of MIRDIN11.1 PEIC TNTNI I I HOW i__ INSTALLATION WILL SIEVE: IE^7BgENCE Ya COMMERCIAL❑ OTHER❑ O P� NUMBER OF UVNO UGSra: NUMBER OF 6EOROOM6-_a? NMISIR OF EMPLOYEp: ]� CHARACTER OF ML TO A DEPTH OF I FEET:_I=jPITISUMP BOIL CHARACTER:S` A b. t fA&,J WATER TANS DEPTH U, SEPTIC TANK/LMRABF TRW TypE/MFO_ D r _y CAPACT' A No.COMPMFMENTS PILO TREATMBIT PUNT❑ OHITANCE TO NEAREST. WELL T— FOI/NDATION /r- P110PERrY L1N!_j'��/Q T� LIFT STATION❑ SIZE TYPE OF tUMP SNA OIL SEPARATOR 484CLOSEO SYSTEMI �E•� 4y LIACNNO UNE R NO.6 LENGTH OF ONES DISTANCETO NEAREST:WILLF'JUNDATION PROPERTY LINE (((��((��'''•``•` FXTEt SID ❑WROTH LENGTH_=DEPH/ DISTANCE TO NEAREST:WELL FOUNDATION PIgPERTY LME_ MOUNDED ❑YAnTH LENGTH DEPTH DIIrrANCE TO NEAREST:WELL FOUNDATION FROPFRTY LN! SWPAOF HTS ❑DEPTH SIZE NUMBER DIT"ANCE TO NEATEST:WELL__FOUNDATION PROPERTY LINE SUMPS ❑NAWH LENGTH v OWFIf DISTANCE TO NEAREST!%W Lam_FOUNDATION PROPERTY UNE OIiPoSAL PONDS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:VAU- FOUNDATION PROPERTY LME I HERESY CEK"I THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE 1MTH SAN JOAQUIN COUNTY ORDINANCES AND STATE UBS.AND RULEB� AND REGULATIONS OF THE SAN JOA WN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERrIHE6 THE PJLLOWM:9 CERTIFY THAT N THE PERFORMANCE OF THE WORK PDR WHICH THIB PERMIT M ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MAKER AS TO BECOME SUBJECT TO WOPAMAN•E COMPENSATION LAWS OF CALIFORNIA-- CONTRACTOR'S MR;NO OR St1BC 6/D EIONATWE CLTfrSTES TFE PoLLOWbIO:"I CERTMY THAT IN THE PERFORMANCE OR TTI[1NOH(TOR YMMCH THM PEPSMT b 166UlD,1 BNALL EMPLOY PERSONS SUBJECT TO WOpOMA COMPENSATION U OF ALIPDINIA." THE AP'PVCANT R,T{G!i CA:L_HOW 1N ADVANCE MA1 ALL R[dYl®M4SPEGTOIM. COAI'lET!lM1AWN0 BELOW, I N STONED% TTrIE:_ DATE: ED PIAT►UN m/1AW TO SCALER SCALE "to 1, NAMES OF STREETS OR FIDADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRDPOSED 2. OUTLINE OF THE PROPEFrY,WITH DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. N J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTNO AND PR10pOBED STRUCTUMS, S. LOCATION OF WELLS INITMN RADIUS OF ONEFr.ON INCLUOINO COVERED AREAS @LOCH AS PATIOS.DRIVEWAYS.Alto WALX6. THE PROPENTY OR AP.1011INBSII Pplorlprry. ......i. . ..........:.... :. ... . i .. -. .:.....e.. . . :.. .i.. Nm ._.... ...... ' ........:.. �44 �4 v P4 -rm,A - XS'Tiw: ' i ' ..... . PAYMENT . ZAN .... . ..........i... . . .:. ` ... .IOMION c6mr, CID -—.4—FA.L HEJ4QH DIVISION 6 FOR OIVMTMSNT USE ONLY AMICATION ACCEPR'D BY DATE: AREA:_�_._1� TANK,RT Ury6UJFl NSPEC TION BY T! AL INSPECTIO S r ATE R V ADOITIDNAL COMMENTS: fzU�6Lf�sWQEof Cauu�rrwr/ Ar:coJNnrla ONLY AIDE FwcE C FE CODE FEF NFO AMOUNT REMITTED CHECR/A:ASH RFCEVSO ST DATE ■l G PBIHTi NUBR INVOICEF JO -a 6 '3 8 o� r �