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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,446 N.SAN JOAOUIN ST.,STOCKTON,CA 96201-0388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YFAR FROM DATE ISSUER APPLICATION IB HERESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO C0rPA4S RNCtvr•AND/iR nbf OR INSTALL JOAQUIN COUNTY MVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDAPOS OF BµJOAQUIN COUNTY FVgLIc HEIIL7N DESCRIBED.THIS IFNVIROICAA1nEFONTN,A�MAGE IN COMPUAW_E WITH SAN D HEALTH OINSION. JOS AOOREP9/OR Cftt LOT 812E OWNER'B HAMS ADDRESS A� 0000 CONTRACT PHO.E l 7`•/O y ADDRESS I✓1 O S`' / �/ UCP Gd Z�y:r P1UN ed-s SUBCONTRACTOR APO RETS LK A RroNE TYPE OF'4ERIC WORK: NEW INSTALLAn-m❑ r- TION oE4TRucnoN❑ 010 SEPTIC SYSTEM PERMITTED IF FVBUC SEINER 18 AVAILABLE WRMIH 200 FEET OF BUILDING.) �,y TIER P91C TESTI-I E 1 NOW MANY M27ALLATION MALL sUNE; IEetOENC COMMEFLCIALlII O APDg.tlan ❑ NUMS�[OF UVRLO UNITS: Nmmm.OF IwRO 8 NUMBER OF EMPLOYEES: MEMCCHARAC7ER OF 901E 70 A DEPTH OF 3 FEET: MP 801E CHARACTER; 7 WATER TABLE DEPTH v SEPTIC TANKmRFA4G TRAP TYPElMFO CAPACITY Q PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL_/D�' -t NO.COMPgRTMENTBT` FOUNDATONyS� TROPERTY ME,_r f LIFT STATION❑ smE TYPE OF PIU�MP =0 BAND OIL SEPARATOR IFNCICBEO SYSTEM? _ LEACHING UNE YF NO.p LENGTH OF LJNE.B —')- FILTER l V I I DISTANCETO NEAREST:W"Q/� FOLNCATION1.d,t PROPERTY UNE_� MOUN SED Q WIDTH LENGTH OEPTM DISTANCE TO NEAREST:WELL -101- MOUNDED FOU!NDATIpN PROPERTY UNE �`,,❑WIDTH S®AGE RTS LENGTH. ' OE�H �DI6TANCE TO NEAREST:VYFIL`T FOlMDA710N plpPEgT1,UNE DEPTH 512E NUMREq DISTANCE TO NEAREST:WELL�ro� fOUNOATION �r� SUMPS ❑WIDTH IENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATION PROPERTYUNE_ -� 'T DISPOSAL PONOS ❑WIDTH FROf4NTY LME LENGTH_DEPTH DISTANCE TO NEAREST:WELL` fOUNDATION -- PROPERTYLINE 1 HEREBY CERTIFY THAT I HAVE PREPARED TH1B APPLICATION AND THAT THE WOR(WILLSE DONE IN ACCOROANCE WITH SAN JOAOUIN COUNTY ORDINANCESµD STATE lAW6, AND REGUU.Tw$S ED,I SHANJOAOUIN COUNTY.HOME GRANT ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLL 3AN•ICERTIFYTHATINTHE PERFORMANCEOFTHEWORKFAND ORWHICH THIS PERLLR W IBBOED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WDRKMAFYS COMPENSATION LAWS Of CALIFORNIA' CONTRACTOR' HR RU OR LES BUB'CONTMCTNG SIGNATURE CERTWIE9 THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOH WHICH TWB WOFKMµ'S COM IATION LAWS CAJUFORM&-THE APPLICANT MINT CALL 24 HOURS IN ADVANCE FOR AU.REOUIIED INS pMs.ICOMFRETF sSUED �EMPLOY PER.WNS SUBJECT TO DRAWING BELOW. elONm X ` n - TRIF:_ T DATE• // 7 PLOT PLAN NIUW TO SCA!EI SCALE 1.NAMES OF STREETS OR ROADS NEAO�ST TO OR SOUNDING THE PROPERTY, A 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 0.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. INCLUDING COVETED AREAS OUCH AS PATIO%DFOVEWAYB,AND W S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON ..... THE PROPERTY OR ADJOINING FROM, € :.. PAY ....... ' f Ga1171995 �. �lJIrt4Clxra!, .. i. L-H RVlE LN/Eh tiA a TH L)iV(5 I jopj ...... .... ......... .......... D �.. i T FOR DEPARTMENT USE ONLY '•W__- _ r- `, APPLICATION ACCEPTEDBY T /y `�•T �IpR �t_PATE: F 7 AF�A:_Z �Z TANK V SUMP yrs: TION B`! DATE]!jC(/'[.JFINA[INSPECTION gy —__`. 7� ADDITIONAL COMMEN,IS: ACCOUNTING ONLY; NW FAC# PECOVE PEE NFO AMOUNT REAlTTEO CHEC MASH RECEIVED SV DATE SR/PERMIT N 31 Lb I?