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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OfVIS10N <br /> P.O.BOX 988,304 EAST WEBER AVENUE,STOC"M CA 95201388 <br /> (209)488.3420 <br /> HR-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM PATE ISSUED <br /> (capula H Tf*lSul _. <br /> APRICATION 16 H^REOY MADE TO THE SAN JOAQUI N COUNTY FOR A PEIWfT TO CONSTRUCT AND"INSTALL THE WOFK DESCRIBED.THIS AFFUCAFWN b MADE N COMKIA#4m INRN 6AN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 0-1110.3 AND THE STA DARDS OF BAN JOAOUN COUNTY PUBLIC HEALTH SEAA%WEESS,,EEN�VIRONMENTAL HEALTH DIUtEON. <br /> JOS ADORES810A APN,' / f O A ,, CRY / �/'/C•R/ _LO7 SI$E3•SA�ti <br /> O.YNER'8 NAMET(JI�L� 1. y7'gl�,i�,(• ADDRESS��7'F/ J q/Dm g eo S r 7 <br /> CONTRACTOR O�-i-i .7 �UO�F_ ADDRESS 2 l� "L`alr'• 77Y BGG) ' <br /> ,� � Llct PHOH�� <br /> SUB CONTRACTOR AOOIRE6S UCI �F'HOAIE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O RSPAMIADDITION DESTRUCTION❑ <br /> INO SEPTIC SYSTEM PEIW ITTEO F PVSUC SEWER IS AVAILABLE WRHN 200 FEET OF elD RN0.1 POW TE[TM E 1 NOW ASANV <br /> w.`�� 5•�'�G r+[2r�tt� A/�wueF.s <br /> INSTALLATION WILL SERVE: RESIDENCE 0V"cOMMERCIAL❑ OTHER❑/*0r7c, 4` �QtiKL2j/ <br /> NiMLER OF LIVING UNITS: PROMBEIR OF SEDROOM{: NUMSER OF FRAMOYIUM: ^7 <br /> CHASAI6�(R OF 800.TO A DEPTH OF J FEET ./'PRlS^/11�•IP BOIL CHARACTER- WATER TABLE DEVTIL,112 <br /> lS/ECTIC TA'{'IKMREA;"TRAP ❑fwE71,IF0� ic.c - f (,- CAPACITY 110&0 NO.COMPNTtMENTB <br /> PKC TREATMENT PLANT 0 INSTANCE TO NEARLSI: WET}, /J�t1_) FOUNDATION (O� PRDT4RY LINE /QO/ �••� <br /> 1!7 STATION❑ SIZE TYPE OF PUMP —SAND ORI,SEPARATOR IENCLOOM SYS7EMI <br /> ULACHSW LINE �❑ NO.S LENGTH OF LINES DIRTANPI <br /> CE TO NEAREST:WELLFOUNDATION DPFM'Y NNE <br /> FILTER LED /dq WIDTHC'4�0 LENmm--L'DEPTH y2, DISTANCE TO NEAREST:WELL FOUNDAtION_?e ' PROPERTY tw /007— <br /> MOUNDED <br /> 00/MOUNDED ❑WIDTH LENGTH_DEPTH DISTANCE TO NEAREST:WELL _F01NlDATION PROPETSTY UNE <br /> SEEPAGE PITS ❑DEPTH 817E NUMSFA DISTANCE TO WAMOT:WELL__FOUNDATION POPOTY LINE <br /> SARAM 11 WIDTH LENGTH Of PTH DISTANCE TO NEAREST:WELL FOUNDATION PROPEMY LINE n <br /> DISPOSAL PONDS ❑WIDTH "�- <br /> IENOTH DEPTH pSTANI TO NEAREST:WELL FOUNDATION PROPERTY LIIIF <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MRN SAN JOAOLAN COUNTY OROINANCES AND 07ATE LAL M,AND RULED <br /> AND REGULATIONS OF THE SAN JOAOUIN COUNTY,HOME OWNER OR UCENSEC AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIF/THAT N TW PERFORMANCE OF THE WORK POR WHICH <br /> THIS PERMIT IS ISSUED,1 9NOT OY ANY PERSON IN SUC MANNER AS TO SECOME SUBJECT TO WOFILMAN'S COMPENSATION LAWS OF CAIFORNIA_'CONTRACTOR'S MNN:O OR <br /> =O SWAT= 11 FOLLOWNO:T THAT IN HI!PERFORMANCE OF THE WORK FOR WHICH THIS FUMIT IS ISSUED,I SHALL.EMPLOY PERSONS SUBJECT TO <br /> WOWL 'B CO CA U.' CRL2.24 NOW IN AVVANCE FO(RR A_LL,PWMM40 I�/"PECTIONS. COMPLETE OKAWHO BELOW./ �j <br /> SIGm .x TI:'LE: 1 I/l'✓"4C I DATE:_ TIC / K� <br /> L• PLOT PLAN IDRAW TO SCALD SCALE 'Ie <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. S.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2,OUTLINE OF THE PTIOPER'TY�WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> a. OSNENSIONEO OUTLINES AND LOCATION OF ALL EKIBTINO AND PROPOSED STR MTURES, E,LOCATION OF VEILS WITHIN RADIUS OF ONE HUNDRED FfF Y FT.ON <br /> INCWDIND COVEPED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE FYOPERTY OR ADJOINING PIOPEKfY, <br /> E, <br /> � VV <br /> +Gj <br /> .... <br /> S <br /> ...............:. ..;.... : ._,.. r�lad - <br /> rI <br /> MR DF7ARTMENT USE ONLY )r <br /> APPLICATION ACCEPTED By l DATE: I lP ARE,��+� Cay <br /> TANK,PR OR SL%V INSPECTION BY DATE---1 J FINAL INSPECTION BY DATE�i <br /> ADOTIONAL COMMENTS: <br /> I <br /> j ACCUUNTINd ONLY: AID, FAC/ <br /> CODE TEE IMO AMOUNT R9iI1TTEp HPC KASN —I.— DATE SR IPIRN"Numm INVOICE, <br /> b D D3 <br /> SFZDDt�a.!'7 ) <br />