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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 ROR'REFURDASIE PERRT EXPIRES 1 YEAR FSOM DATE ISSUED ICBRPlato ie Tripicat.) APMATION IB HEREBY MADE TO THE BAN JOAOUIN COVNTY FOR A If MOT TO CONSTIRJCT ANDOR INSTALL THE WOTR OEBCRl9fO. THIS APLKATION IS MADE N COMPLWAT.E WTiN DAN JOAMIN COUNTY DEVELOPMENN�TJJ TITU,CHAPTERR 0.1110.3 AND THE STANDARDS OF LANJOAOUIN COUNTY PUBLIC HEALTH BERMES.ENVIRONMENTAL HEALTH DTNSLON. JOB ADOMS91oA APR! N:!\ y `�} [�,(�jn/1 A J /J CITY. -Yp�/4)1 �COT TSSM OWTER'6 NAME��Te✓ /i% AN(lF//�-.ADOREDS .-�1�� .�T7 /`/��//7 SLG,- CONTRACTOR r (II r ADOREBBUCJ 4, SPHPO—ME_E]Y 7MY-2^7ZJ Z7� SUS CONTRACTOR ADOW" IICI PHONE TYPE OF 60MC WORK: NEW INSTALLATION❑ REPAWADd TON MTRUCRON❑ OM BLPTIC SYOTEPJ PERAE M If PUBLIC SEWER R AVAILABLE WITHIN 200 FEET OF SUSDING.1 PSRC TSOTIPI 1 1 RXYW MANY INSTALLATION WILL SERVE: RESDENCE j? COUMERCLAL❑ OTHER❑ WARIER OF LTVINO UNITS; 1 Admo R OF SmROoMS: NMNBLR OF PAPLOYM CHARACTER OF SOIL TO A DEPTH Of JPEER: :nCPITIBUMP SOIL CHARACTER: 5—d- WATER TABLE OEPrq SEPTIC TANK/0REA"TRAP ❑TYPE&WO CAPACITY NO.COI:PAATMEMO PRO TREATMDIT PLANT 11 DISTANCE TO NEAREST: WELL FOUNDATION PRDPERry LSE LIFT STATION❑ SIZE TYPE OF W UP SAND OR SEPARATOR IENCLOSED SYBTEM7 LEACH IG UNE ❑ NO.a LEHOTH OF LINED_ MOTANCE TO NEAREST:WELL PO"ATKNN PROPERTY LINE FETYI OED ❑WROTH UNOTH_ DEPTH DISTANCE TO NEATEST:WELL POUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENOTH DEPTH 046TANCE TO NEAREST:WELL MUNOATION PROPERTY LINE SEEPAGE PITS ❑DEP H //////�� SIZE �A NUMBERZ�q DISTANCEFOUNDATION_ PER TO NEAREST:WELL PROTY LINE SLBN►S ❑WIDTH LLNGTH_Z('/ DEFIIIDISTANCE TO NEAMOT:WEl1 ~FOIINDATION PIOPERTY ERNE DISPOSAL PONDS ❑WOTH LEMTN LIEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COIMTY ORDINANCES AND STAT!LAWS,AND RULES ANO TEOULATIONO OF THE SAN JOAOUIN COMM HOME OWNER ORMENAVO AGEM'O SONAT VIRE CERrEEB THE F0110NNG:'I CERTIFY THHAT IN THEFEAFORNEANCE OF THE WORK FOR WHICH TARO P0"T ISISSUWD I MALL NOT EMPLOY ANY WISON N MHA MANNER AS TO BECOME SUO.RCTM WOTKMATCI COMPENSATION LAWS OF CAUFORHIA.' COPITINCTOR'S/AMNO OR BUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOIMNO:'I CERTIFY THAT N THE PETVDRMNICE OF THE WORK FOR WHICH TIM PHRNT R ISSUED.1 SHALL fIWOY PERSONS SUBJECT TO V4 R AWS COLRENOATION LAWB OF CAL"Rkt�tk""d Tr, APPLICANT NIU►T CALL 24 HOURS N ADVANCE PORI ALL RIOLI1m INS►6CTONS.COMPETE DMLW04 WLCW. SORTED X ��; /T�,(/� TTRE: ��!"/-f �'C.;� f- _ _-DATE: PLOT RAM DRAW TO B[:Alll SCALE 'to I.NAMES OF STREETS OR ES ROADS NEART TO OR SOMOINO THE PROPUTrV. 4.LOCATION OP HOUSE SEWAGE DISPOSAL SYSTEA OR PROPOSED 2.OUTLINE OF THE PROPERTY,MTN DIMMEW ENPONS AND NORTH DECTIOW EXPANSION OF OAOE DPR VIAL OYSTLPAS. O.VkWNSONED OUTUN19 AND LOCATION OF ALL EMOTING AND POPOSM STRUCTURES, 6. LOCATION OF WE"WITHIN RAO"OF ONE HUNDRED FIFTY FT.ON INCLUDING COVEAM PREM WCH AD PATIOS.ORWFWAYS,AND WALKS, THE PROPERTY OR ADJOMMA PIOIERrY. <.... :. ........ ...... 0 o.I ...... s .... ............. :.................... ... ... fi.. .. : ..... r,KY .. ..... ....................... .. Nr Nv .. ....,...... v . . .. - .......... .......................... ....., ...... .. .. ... .. ..... .. .. ..�........................:...t..... .. ..cHv1N.li'iFhLTHNs ' .. ..... .......:.............................................................. ........ :....... ... .....:.............t_. ...:... ... ... ..... ..... .......... ...... .. : � FOR TMENT U1E ONcr �[/., APPLICATION ACCEPTED BY l� DATE: V v NIA yd TANK.PR OR SUMP NW CTIOII BY 71IDATE f ! HNµNSPECTON BY TE �I -7 ADENT1ONALCDMMENIS: ACCOUff" J ONLY: ADI In— ft COVE n—KCOVE FFI INFO AMOUN7 IREUS I TED ASN REC SY DATE m P9NfY"UNISM i sRooaaca(o Pub.HieaM Sart.-Emnro.174(9/96) Y