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oaa32q <br />APPLICATION FOR LIOUIO WASTE PERMIT <br />SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />12091488-34213 <br />NON-SEFUNOAULE PERMIT UPIRES 1 YEAS FROM DATE ISSUED <br />(Couple. In TT*Ikob) <br />APPLICATION IS HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOlOR INSTALL THE WORK[ DESCRIBED. THIS AFTI.ICATION M MADE IN COMP'jANLE WRN BAN <br />JOA(UIN COtBUT UEVELOPUEW 7RLE. CHAPTER 0-1110.3 ANDTHESTANDARDS OF SAN JOAO N COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DPMIDN. <br />JO {` <br />S ADORESSlOR//APNY__5_ &(O Iii) /fe/A4 CRY �;eo4 -// _y LOT SIZE <br />_ C, <br />O',""'S NAMED,-.-.,• •C CO`oTLS/WL.A /LiS'l _ADDRESS_/j'F{.-N�,1{'L s / �% �J �.�J� (,�7 PHONE O�1/ � Ly Sr 7 <br />CONTRACTOR „///( D.E� i OXl .7 r G- ADDRESS / Z � C/LL�l�7'/ ?Si. 7T'K LILY of PHONEY(/ <br />SUBCONTRACTOR ADDRESS <br />UCI _PHIDIIF <br />TYPE OF SEPTIC WORK'S NEW INSTALLATION Q RIPAWADDITION DEATRLICTION Q <br />IND SEPTIC SYSTEM PERwRTED F "UC SEWER 18 AVAILABLE WRHN 200 FEET OF SU fNO.I FERC TIBTtO C I HOW MANY <br />L/ <br />c.<J r ` �� !�IF'I ✓G 'QT`7�7f� A.plo.elPP <br />iNSTAiLAT1ON WILL BEBVE: RESIDENCE L COMMERCUL ❑ OTHER O /)f'V- Q` (Qt�� <br />NLIABHR OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF aMLOYIECt: <br />CH ROF SDA TO A DEPTH OF -3I FEET O *- PTTALIMP SOIL CHARACTER• WATER TABLE DEPTIt v26 ! <br />SPDC K/PIREAsf TRAP L.I T,7E//AFO� - L CAPACITY (OSLO NO. COMPARTMENTS 2 ) <br />MLT <br />PKC TAFATRT PLANT 0 DISTANCE TO NEAREST: riELL D%L(J FOUNDATION (O � PMNgRY LWE /cs� <br />LIFT STATION ❑ SIZE TYPE OF PUMP 8AN0 OIL SEPARATOR WNICLOSED SYSTEM? <br />LEACHING LINE X�13NO. •LENGTH OF LINES �/DISTANCE TO NEAREST: WELLFOUNDATION FROPERT'Y LINE <br />FILTER EEO AMMOTHa_ LEMM_y��-._DEPRM.Y DISTANCE TO NEAREST: WILL FOUNDATION;?0 PROPERTYIMFIE!00 <br />MOUNDED ❑ WIDTH LENDTH OEPTfI DISTANCE TO NEAREST: WELL ^FOVNOATION PROPERTY UNE <br />SEEPAGE RTS ❑ DEPTH Y@E -NUMBER DISTANCE TD NEAREST: WELL_ FOUNDATION PROPERTY LINE O <br />61IAW ❑ WIDTH L1710tH DEOTM DISTANCE TO NEAREST: WELL_ FOUNDATION PROPERTY UNE n <br />DISPOSAL POND{ ❑ WIDTH LENGTH OERN DISTANCE TO NFAPEST: WELL_ FOUNDATION PROPERTY LINE <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUD TION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES ARID STATE LAWS. AND RULES <br />AND REOU.ATS ISS OF THE <br />SaW JOAOUIH COUNTY. 110 W OWNER OR LICENSED AGEHT'V SIGNATURE CERTIFIES THE EOLLOWMO: -1 CERTRFYTTIAT IN THE PERFORMANCE OF THE Y40PKC FOR WHICH <br />TORS PERWIIi IS ISSUED I SHALL NOT Y ANY {{gSON IN SUC MANNER AS TO SECOAff SUBJECT TO WOF"AN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR -S HRUNO CR <br />p"CO, 6 T11RE 8 FOLLOWING:WORKFORWHICHTMBPOAMMISSUED, ISHALL, EMPLOY PERSONS SUBJECT TO <br />AT CA IA.• CAl2b 110W III ADVANCE FJR ALLREEQUIREDPUPPCTOM. COMPLETE OKWM40 BELOW,//`Z- �b 7 EJ. PLOT MN IDRAW TO BCALE7 SCALE ' ro <br />1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. —' E. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OU'TUNE OF THE PNDPLTRY, WITH DIMENSIONS AND NGRTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES ANO LOCATION OF ALL EKIBTING AND PROPOSED STRUCTURES, F, LOCATION OF WELLS WITHIN RADIUS OF OPE HUNDRED FIFTY FT, ON <br />I NCLUOINO COVEPED AREAS SUCH AS PATIOS- DRIVEWAYS- AND WALKO. THF FyK)_ OR AI1vLNINn --- <br />I <br />R -- <br />C/� FOR DEPARTMENT USE ONLY <br />APPLRCATION ACCEP.'ED BY v �- DATE: Z 1 V7 TD AREA,�� <br />TANK, PIT ORD" INSPECTION <br />�BY� /��} DATE, <br />( ! ! FINK INSPECTION BY DATE,, I7, <br />ADDITIONAL COMMENTS: _ t,..ICFLQ/�yL..i!( t}_} -'L -, ` A , n LPA 1, t% <br />I ACCOUNTING ONLY: <br />I AIDE I FAC/ <br />11 <br />of CODE PEE RTO <br />AMOUNT REMITTED I EIEC /CAIN RECEIVED BY DATE <br />MR ! PBapT NULISET INVOICE <br />L� __ <br />SRDDI,+a 1 7 <br />