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000"Z99 <br />APPLICATION FOR LIQUID WASTE PERMIT <br />SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES 01 <br />ENVIRONMENTAL HEALTH DIVISION `D <br />P.O. Box 388, 904 EAST YQEBER AVENUE, STOcnoK CA ` mi -m <br />(2991489-3420 1 <br />NON-REFUNDABLE PERMff MPMES I YEAR FROM DATE ISSUED <br />?cfwItft iA Tr*Akttt) <br />AFRICATION IS 49WRY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK OESCItBEO. THIS APPLICATION IS MADE IN COMPUANCE YRTH SAE: <br />JOAQUIN COUNTY DEVELOPMENT TITLES, CHAAJPTSA 9-1110.3 AND 77 <br />ANDARIO9 OF SAN JOAOU COUNTY PUBLIC HEALTH 8ERv10Ee, EHNRONMENTAI HEALTH bIV18'gN. <br />JOB ADOAE66JGB A1M1 �• �� CITY _'Lpr7 yR`EF/`/p <br />OWNER'S NAME N C Q t(JLNL K ADDRESS PNONE/�h1 -4/O17 <br />BUS CONTRACTOR ADg1EBe L1CP PHONE <br />TYPE OF SEPTIC WORK N!'N INSTALLATION ❑ R9AIVADDITON MTMXnON 0 <br />ING SEPTIC SYSTEM PERMITTED IF PUSLRC SEWER M AVAILABLE WITH N 200 FEET OF BUIL NO.1 ►BIC TESTIV, 1 1 NOW MANT <br />APDIUSSp, J <br />INSTALLATION WILL SHNE: RESDENCE COMMERCIAL CJ OTHER ❑ <br />Nl1A($i OF llVINO I1NITt:_= NU4RB[T,I}OP iWROOMt: NUFABER OF ONPLAYETf: <br />CH R OF BOIL TO A DEPTH OF 3 FEET E p{fI811MP BOIL CHARACTER: WATER TABLE DEPTHL �Q 'Y <br />C T 70RCAt! TRAP ❑ TYPERAFO ^ — <br />1 CAPACRY NO. COMPARTMENT* <br />PRG TREATMR <br />ENT ANT Cl DISTANCE To NA.% <br />CARMIT: WELL FOVNOATION I'S , PROF4RTV LINE/00 r <br />IST STATION O SIZE TYPE OF PUMP BAWD OIL SEPARATOR (ENCLOSED SYSTEM( <br />LEACHMO UNE ❑ NO, S LENGTH DF UWS_ O16rANCE TO NEAREST: WELL FOUNOA710N TMOPERFY UNE <br />PLTCR BED ❑ YROTN LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br />MOUNDm QWIDTN LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LME <br />SEEPA01 FITS D vowt Wr NUMBED DISTANCE TO NEARE87: WELL POUNOATION PROPERr'/ LANE <br />SSS 1N: -3I WIDTH LENGTH DEPTH DISTANCE TO NEAREST: V*U__ FOUNDATION PROPERTY UNC <br />DISPOSAL PON" 13 WIDTH LEJIOTH DEPTH DISTANCE TO NEAREST: WELL_ FOUNDATION PROPERTY UNE - <br />4 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPIICATIDN AND THAT I Y WOR( WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE (AWS, AND <br />RULES <br />AND WGULATONS OF THE SAN JOAOUW COUNTY. HOME OWNER ORUCENSED AGENT'S SMNATUPE CERTIFIED THE FOLIDWMO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORN POR W111CH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON SUCH A MANNER AS TO BECOME BUBJECT TO MP4WAN'S COMPENSATION LAWS OF CALKOMUA' ODNTRACTORT NUUM OR <br />SUSSO CE THEFOLLOWING• CERTIFY THAT IN 171E PERFORMANCE OF THE WORK FOR WNACN THIS PEVAIT 16 ISSUED, 1 SHALL EMPLOY fUMNS SUGJECT TO <br />WORKMAN'S OMPE N OFC WT CAU. K NOIAlt M ADVANCE Win <br />/ALL <br />REOUWED 0SPECT1oNS. COMPLETE ORAWMNO %aZW. <br />SIGNED X TT:1E: DATE: �♦/j.Q D �47 <br />PLOT RAN MHAW TO SCALE( SCALE <o <br />1. NAMES Of STREETS OR MADS NEAREST TO OR BOU N04NQ THE PPOKRTY, 4, LOCATION OF F10USE SEWAGE OIWOSAL SYSTEM OR FIOPOBED <br />2. OVTLINE OF THE PROPERTY. WITH DIMERT <br />DIMENSIONS AND NOH DIRECTION, EXPANSION OF SEWAGE dBPOSAL SYSTEMS, <br />]. OIMEJNSONED OOTUNES AND LOCATION OF ALL EXVTINO AND f"OPOSED ETRUCTURES, S. LOCATION OF INSULA RADIUS DIUS OF ONE HUNDRED FTM FT, ON <br />tNCLUD94G COVERED AREAE SUCH AS PATIOS, DltPAWAYD. AND WAUUt. \ THE PTgPCRTY OR AIL,N)pSNO PISOPlIrTY, <br />—_ <br />f <br />+ y` <br />�� le 74.4. <br />k <br />r-11 <br />PAY <br />C <br />. _. ... ..... ... <br />.. <br />OCT 1 f"ll .._:..... <br />---a- <br />.,LIAGTcEs <br />UIN <br />ON6•fENTtaI:H $Ef <br />W 'li Pr{'f ' 'OWRC <br />!ON• . <br />Pon OePA.TMDIr 111E ONLY <br />APPLICATION ACCEPTED BY DATE: ,(C MEA. <br />TANK, PIT OR SUMP INSPECTION BY DATE l T= N__�._['Woy.:� FINAL IFA=OON SY / - ,per GAT' -40 <br />.4 1 iV 1� 1�� <br />�. /l—. <br />ADD-ONAL C JMMLNTfl- <br />ACCr.UN11NO ONLY: NDA FAO( <br />PE COD! FPl1MFO AMOUNT V40ATTM /CASH RECOVER SY DATE ✓M / PCIIMT NIIWEIBI INVOICE IF '1 <br />a 9 <br />SR 001--A(� <br />