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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 17W (209)468-3420 ,n . NOB-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED , �_ {Cowlsu In UptkBtol APPLICATION IO HEREBY MADE TO THE MN JOAOIIN COUNTY FOR A PERMIT To CONSTRUCT AND.OA INETALL THE WORK DESCROED.THO APNJCATION M MADE N COMPLIANC[V TH SAN JOAOUIN CO,my OEVElO�PBEE�NT/TF�T�•{-[RCHAPTER 9.11 10.7 AND THE TTANDAPOS OFF SAN JOAOUgN COUNTY PUBLIC HEALTH 86RV CIIL N'OR4RRONMENTAL HEALTH ONIMON. i JOB ADDRESNOR A°FI/ 1 I"EAM.`./ GF%'EJ�7t �1�-�r�,L, CFFYF'^' L:1T YI2F r1CL` OWNER'S NAMEEyy�y AWREBB •5-�-"T� �-+• RIONE_ pmt CONTRACTOR f`13 cE- �- AnolEss� 0 �ulc BIM CONTRACTOR ADM..ADOIREB LIC/ i'iIONF TYPE OF SEPTIC WORK: NTW INSTALLATION❑ PIPAIIVADDITION❑ DESTF=T70R IND SEPTIC SYSTEM MWAMEO IF KR9L1C SEWER W AVAILABLE WITHIN 200 FEET OF W SDIN0.1 PRC T8STH1 I I NJW MANY AFPSAAMR F_ INSTALLATION WALL S9NL IEBOEMCE❑ COMMFTICIAL❑ O7HFR❑ mUMSM OF UVIMG UMTS: NUMLSR OF SEOHDOMS: NU119t OF EMPLOYEES: CHARACTER Of SOL TO A DO"OFI--3 RET:_ PR/BLNAP BOR CHARACTERL WATER TABLE DEPTTL_ SEPTIC TANIR/OKASE TRAP 11 TYPERAF.1 CAPACTTY No,coMPARrANNTS FRED TRIATMOFT PLATN-FT 13 DISTANCE TO NEJR&IT: WELLFOMDATON RIOPEHTY LME LIFT STATOR LJ 812E TYPE GF R1MP BAND OL SEPARATOR IENCLO8ED BYSTEMI LEACISNO LINE ❑ ND.B LENGTH OF UNEB_ DISTANCE TO NEAREST:WELL FOIN SATON PROPEIOY LAE RLTw SED ❑VA0714 LENGTH—Dmm DISTANCE TO NEAREST:WELL POIEMATIdY AOFPTIY UIE MOLDIDED ❑1NDtN LENOTH__OEPTN DISTANCE TO NEAREST:WELL FO NDATION PROPERTY INE SEbAOE RTS ❑OM14 SQE NUMINER DISTAECE TO NEAREST:WELL FOLN DATION PROPENTY L1! SUMPS ❑WOfH ttWT1/ _DEP H DISTANCE TO NEAREST:WDA.—FOUNDATION PAll"WrY LONE DISPOSAL PONDS ❑WW7H LENGTH .DEP H OMI MACE TO NEAFEAT:WELL__.FOUNDATION PIOPELRY UNE- 1 HEFESY CERTTY THAT 1 HAVE PWPMED THIS AFRICATON AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUlN COUNTY OLO14ANC26 AND RATE LAWS,ANG PULES AND RFOUTATONS OF THE SAN MAO IN COUNTY.HOME OWNER ON UCFIISED AGENT'S SIONATUPE CETRSIEB THE F'OLLOrN":'I CERTMFYTHAT INTHE FEIEOPM NCE OF THE WORK RORYVBcN TNM rewrr■ISSUED.1 BNLLL NOT EMA.O PERSON N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COIMENM71oN LANM G CAllrOIBAA.'CONTR,ACTOR7 NSM OR aL16-CONfRACTINO IIONA7URE CORNIES FITfIPY THAI-NTN[PEFSONAANCE Of THE WORE MI(1�NCH Two PUILUT IB ISSUED,1 SHALL EMPLOY PERSONS SULECT TO WOIKLENI'S COAE9MATMON L__OF C MA.' THE A17 CANT NNii CALL 24 HOURS N ADVANCE FOR AL,_ RNBCTTONS.COMPLETE OPAWr B BHLRM. J /yJ r SIOWD X �� L 7RTLE:_ DATE- PLOT PLAN OmR TO SCAM SCARE `iH F.NAMES OF STRUTS OR ROAOB NEAREST TO OR BOUNERNG THE PMPORY. 4.LOCATION OF HOLM SEWAOE DISPOSAL SYSTEM OR TOPOSED 2.OUTLINE OF THE PROPERTY.WDH DIMENSONB AND NORTH DBECTION. EXPNEODN OF SEWAOT DISPOSAL SYSTOAB, 17. O.OWUMONED OUTLINES AND LOCATION OF ALL M87NO AND TOPOBW STRUCTURES, f.LOCATION OF WEU§WNFSN HAD"OF ONE HUNOREU FS`W FT.ON twLUD NO COVERED MEAS SUCH AS PATIOS,OLBVEWAYB,AM WALLS. THE PN0PERTY OP AD.OR"RAP9ETY, �:�—lllo i cisTi,rfG ....: s'CFoto/c 7W.Zve; I Al .. .. .... . . .. ..... .. d ... .:.... ....w ° .. ti .......... .. ... ........ ........ .... ........... :. .. .. ;...PAYMENI`;..... .I tt` . . SEP.2 4199 .�. : .. � � ,_.�..... . . ......:.... .. SAN JUALYON(A .: ............ i .. .. ._ ENVI NMENTA LTti II. ;Il d:. FDR oF➢ARTASOIT uBM O/LLY �� ©� APPLICATION ACCLFTEO NY OATE9Q,Q••- TANK.PIT OR BVMPOWIECTON BY DATE_FINAL MSPECTON BY LLL_GC.LCS/ AW11ONAL COAMME'•— ACCOU"%0 ONLY: AIRF FAtA FE COoE FTG 1NFo AMOUNT RDAITED ASN RLE: BY DATE M I PONST NI/ABI INVOICE! Pub.Health fiery.-EDVWfo.174(3196) 1