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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, SOX S88, 904 EAST WEBER AVENUE, STOCKMR CA 95201388 Ixael aeesa10 al -1, 9,5/ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR F"O,Y DATE ISSUED K4%wlNCN it Tr}lilmt I APPLICATION 18 HEREBY MADE TO THE BAN JOAMN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORN DESCRIBED. THIS APPUCATION IE MADE N COMPUAr10E WTIL SAN JDAOUN COUNTY XVELOPPMAEEN_T TTfILE, CHAPTER 9-1110.3�/AANDf THE STANDARDS OF SAN JOAOUN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMEENTAL HEALTH DMBION. X18 ADDRE8MR APN,. J S 1 (IV 7- 2 k>4% CITY /yiL y 6'A _ LOt &ZE CWHER'S NAME �GIJ P.¢r ADDRESS,^r - L PHONE p�-i+T /J✓ ��'j CONTRACTOR ''Jn +� 5�� ,ADDRESS /(/�bM M £ uL ucE_ BUB CONTRACTDH ADDFESST LjcE PHONE- TYPE HOSTYPE OF SEPTIC WORK: MEW INSTALLATION,0 REPAIVAODSTION ❑ DOTIRxI,oN ❑ Mn SEPTIC SYSTEM PERMITTED IF PRBOC SEWER 18 AVAKASLE WITHIN 2DO FEET OF BUILDING.I PFPC TFATW I 1 NOW MANY APWwSaP INSTALLATION WILL SERVE: KIINANCE�L� COMMERCIAL ❑ OTHER ❑ 7 Ml/MR691 OF UVNG UNITS NUMNAI OP EEDROOMS: J NUMSSeT OF PLROr[U:�'- CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PT/SUMP Mt CHARACTER: WATER TABLE DEPFH I V, NEPTIC TANKIOREAGI! TRAP ;JTYPEw F0_ L TG • CAPACM .OD NO. COMPARTMENTS ►Ka TREArmwr PANt ❑ OISTANCE TO NEAREST: WELLam FOUNDATION 30, Rn "kRIY UNE UFT STATION ❑ mzE TYPE OF F %MP BAND OIL SEPARATOR IENCLOSED 8YSTEMI LEACISNa uNE -E NO. A LENGTH OF UNES^ __ �2 ' X/00' DISTANCE TO NcAmerr: WF1L62�9 L FOUNDATION PTgpwry UNE FILTYI S10) ❑ WROTH LENGTH__ DEPTH DISTANCE to NEAPEFT: WELL _ FOUNDATION PROPERTY LINE MOUNDED ❑ WIDTHLENGTH _ DEPTM DISTANCE TO NEAREST: WELL _ FOUNDATON PFIOFERTY UNE SEToAOE PTT$ ❑ DEPTH SIZE _NUMBER DISTANCE TO NEAREST: WELL_ FOUNDATION PROPERTY L)NIF NUNIPI 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL_ __ FOUNDATION PROPERTY UNE DISPOSAL PONDS 13 WIDTH LENOTH DEPTH DISTANCE TO NEAREST: WELL FOIRDATION PROPERTY UNE w I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 8AN JOAOUIN COUNTY DIOINANCEB AND STATE LAWS, AND RULE@ 9''7 AND REGULATIONS OF THE SANJOAOUN COUNTY- HOME OWR4R OR LIC ENSEO AGENT'S 810NARNIE CERTFF8 THE FOLLOWINO!'I CERTIPYTHAT N THE PERFORMRII PERFORMANCE OF THE WORK FGWN:H i'••l THIS r[PFArr IS ISSUED, I SHALL NOT EMPLOY ANY PERSON N OUCH A MANNER AS TO BECOME SUBJECT TO V"AMAW8 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S KFW4G'pR SUB{DHT RACTIND SIGNATURE CERTIFIES THE FOLLCWINO: 'I CERTIFY THAT N TEN PE/EORMANCE OF THE WOM( FOR WHICH TMS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIfORM THE A "IR MUST l 2A IOW N ADVANCE FOR ALL MIAMI= INSNI'.TLDNS. COMPLETE DRAWING BELOW. SIGNED )(� I.� 1 e+L'�J TP LE- PLOT PAW (DRAW TO SCALE] 1, NAMES OF 67REETS OR RDA" NEAREST TO OR BOUNDING THE PROPERTY. t, LOCATION OF ROUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTURE OF THE PHOPERTY, ;TH DIMENSIONS AND NORTH DIRECTION.EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION Of ALL rXM*IG AND PROPOSED STRUC'7URES, S. LOCATION OF WELL$ MTTHIN RADIUS OF ONE M*4DPKD FIFTY FT. ON INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS, THE PROPERTY OR AOJORwNO PROPERTY. PAUZ FJTe1AS' U l� fes, X )5D ,1 p 1° a iLr'► K 2d 9 - 3brd 1 tt1}1 i. J JUN PUBLIC HE> c w^ I - L I M 10`nI 570 41 iyl 00/s-z—b ffJJ�� `` Pow DEpARnuEni LISP ontr APPLICATION ACGELTfD BY _. j ) �p,d•��..�c.� GATE: Y -� � J � T AREA: I�N.E/7V TANK, PTT OR BUMP INNECTq DA7F / f FNAL ..RECTION BY� DATE��•C� f 9� ADDITIONAL GriMMENT@: ACCCUN 7ING ONIY: AIDE FACS I� CODE FEE INFO AMOUNT REMITTED IEHFCKI ASN RECWW SY DATE N I P PHOT NISIAEII INVOICE P